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A COMPLETE 



Handbook of Treatment, 



ARRANGED AS AN 



Alphabetical Index of Diseases 



TO FACILITATE REFERENCE, AND 



CONTAINING NEARLY ONE THOUSAND FORMULAE, 



WILLIAM AITKEN, M.D. (Edin.), F.R.S., 

Professor 0/ Pathology in the A rmy Medical School; Examiner in Medicine for the 

Military Medical Services of the Queen; Fellow of the Sanitary Institute of Great 

Britain; Corresponding Member of the Royal Imperial Society of Phsicians 

of Vientia; and of the Society of Medicine and Natural History of Dres 

den; Pathologist attached to the Military Hospital of the British 

Troops at Scutari in Turkey during the Crimean War. 



! ' 





NEW YORK: 
BERMINGHAM & CO. 

1882. 




COPYRIGHTED 1882 

BY 

BERMINGHAM & CO. 



Electrotyped and Printed by 

W. L. MERSIION&CO , 
39, & 41 Ciinton St., Railway, N. J. 



PREFACE. 



There is, perhaps, no more striking characteristic of the 
medical practitioner of to-day, and none better illustrating 
the pervading spirit of the age, than the universally observed 
tendency among medical men to shun, in medical literature, 
the unrealities of theoretical discussion, and to appropriate 
with avidity only facts which they can instantly transform 
into working force, and the gain from which is conspicuously 
apparent. 

Now and then we meet with a writer who has in part, at 
least, appreciated this demand for the practical, the utiliz- 
able, and has accordingly made some effort to supply this im- 
perative appetite with the proper food. We have, however, 
in the whole range of medical literature, no book which is a 
complete reflection of the treatment of every recognized dis- 
ease, no book which has taken for granted that the practi- 
tioner knows what disease he has to cope with, and aimed 
chiefly to supply him, ready for instant use, with the arma- 
ment he must rely on to win the victory — an armament 
which should embrace chiefly the best methods of treatment. 

A book which is at once concise and comprehensive, which 
is arranged so that the practitioner, given a disease to treat, 
may have before him in a nutshell, the latest treatment re- 
commended by the best authorities; and a book which is, 
above all else, a book of treatment, we here offer to the 
profession. It is composed of the chapters on Treatment 
taken from the seventh (latest) edition of Dr. Aitken's Ency- 
clopaedic work on the Science and Practice of Medicine, 
which chapters have been revised and rearranged, so as to 
make them more available for reference. The reader will 
find that the work does not only embrace the experience of 
its distinguished author, but also that of every known 
authority, 

3 



A COMPLETE 

HANDBOOK OF TREATMENT, 



ARRANGED AS AX 



ALPHABETICAL LVD EX OF DISEASES. 



Acne. — Definition. — Inflammation of the sebaceous glands 
and hair follicles, with retention of the gland secretion. 

Treatment. — Local and general measures require to be 
combined. Diet, in the first instance, should be restricted. 
Wine, spirits, and coffee are to be refrained from. Milk is 
to be used as a drink, and as an article of diet, combined 
with light food, fresh vegetables, and succulent ripe fruits. 
Emollient applications, such as an emulsion of bitter al- 
monds, a decoction of bran or quince seeds, and tepid milk, 
are useful. Dr. Anderson has found sulphur ( 3 i.), mixed 
with rectified spirit ( 3 i.), to be shaken before using it; or a 
mixture of hyd. corrosiv. sublim. (gr. ix.-xii.); hydrochl. am- 
moniae( 3 ss.)cochinillini (gr. i.); aqae. rosoe ( 3 vi.), particularly 
serviceable. Generally, if one fails, the other succeeds. 

In that form of acne common to young women at the com- 
mencement of their menstrual period, Dr. Ringer recom- 
mends. sulphur (3 i.), glycerine (fZ i«)» water (/§ x.), to be 
applied twice or thrice daily. 

AVhichever of these lotions is used, let it be applied by dip- 
ping a piece of flannel into the lotion, and rubbing very 
firmly over the eruption night and morning. Flowers of sul- 
phur used dry to dust the parts with at bedtime is also of 
service. To promote resolution of the induration, iodide of 
sulphur, in the proportion of fifteen or twenty-four grains to 
an ounce of lard, is of great service in dispelling the tumors. 
Drastic purgation ought to be avoided. Simple baths at a 
temperature of %%° or 90 Fahr. are of service. Calomel 
ointment ( 3 i- of calomel to § ii. of lard) has been found use- 
ful, care being taken against salivation. If there be much 
thickening of skin, Mr, Milton recommends the internal use 

5 



6 ADDISON S DISEASE. AGUE. 

of liquor potassae, although inferior to arsenic, which ought tc 
be used. In dysidrosis, the treatment is mainly by carron oil 
to the inflamed parts, with diuretics and tonics internally. 

Addison's Disease. — Definition. — Disease of the supra- 
renal capsules, with discoloration of the skin; or, a morbid 
state which establishes itself with extreme insidiousness, 
whose characteristic features are anaemia, general langour 
and debility, and extreme prostration, expressed by loss of 
muscular power, weakness of pulse, remarkable feebleness of 
the heart's action, breathlessness upon slight exertion, dim- 
ness of sight, functional weakness and irritability of the stom- 
ach, and a peculiar uniform discoloration of the skin, which 
becomes of a brownish olive-green hue, like that of a mulatto, 
occurring in connection with a certain diseased condition of 
the suprarenal capsules. The progress of the disease is very 
slow, extending on an average over one year and a half, but 
may be prolonged over four or five. The tendency to death 
is by asthenia, the heart becoming utterly powerless, as if its 
natural stimulus — the blood — had ceased to act. 

Treatment. — If the disease be recognized in its earliest 
stages, its progress may to some extent be delayed. The 
asthenia, the depression, the evidence of local irritation about 
the suprarenal capsules, and the pathology of the disease gen- 
erally, point to the necessity for tonic treatment and nutri- 
tive diet, the avoidance of all causes of depression, and the 
benefit of rest in bed, and of such medicinal agents as may 
relieve the vomiting. Glycerine, in two drachm doses, com- 
bined with fifteen or twenty minims of the spirit of chloro- 
form, and of the tincture of the sesquichloride of iron, have 
have been of service (E. H. Greenhow). This may be varied 
by the substitution of twenty to thirty minims of the syrup of 
phosphates of iron, quinine and strychnia, in place of the ses- 
quichloride of iron. The greatest caution is necessary in 
using purgative remedies as fatal collapse is apt to follow 
cathartic medicine. 

Ague.—- Definition. — Febrile phenomena occurring in par- 
oxysms, which observe a certain regular succession, charac- 
terized by unnatural coolness, unnatural heat, and unnatural 
cutaneous discharge, which prove a temporary crisis, usher- 
ing in a remission. These phenomena continue to be devel- 
oped in an uninterrupted series or succession of paroxysms, 
more or less regular, which pass into each other by insensible 
steps, so long as the ague lasts. 



AGUE. 7 

Treatment. — It is useless to attempt the cure of inter- 
mittent fever if the sufferer is permitted to remain within 
the sphere of malarial influences. The old empirical treat- 
ment in the English fens was first an emetic, then a sharp 
purge, followed by quinine and arsenic. But an emetic 
must not be given for ague, without regard to the special 
circumstances of the case. Emetics are only of use when 
the tongue is very foul or the stomach overloaded ; or when 
there is nausea and headache with epigastric oppression. An 
emetic will then give great relief, and hasten the stage of 
reaction. In the simple cases, when removed from the 
sphere of malarial influence, active purgatives are always 
beneficial in relieving the full and congested state of the 
abdomen generally ; and they prepare the way for the action 
of quinine, especially combined with diureties, such as cream 
of tartar (Wood). There are also cases of intermittent fever 
complicated with hepatic and other engorgements, which 
continue to recur despite of all means, until a few doses of 
calomel, followed by purgatives, are administered ; then the 
quinine, which before failed, will speedily cure the disease. 
The compound jalap powder,combined with calomel, is found 
very beneficial in such cases. If much urinary irritation 
exist a mixture of 3 vi of bicarbonate of soda, dissolved in 
3 viiss. of water, to which § ss. of Sp. Athens nitrosiis added, 
given in half-ounce doses every two or three hours, with or 
without tincture of opium, will relieve it. Certain morbid 
conditions both of liver and spleen, may produce and main- 
tain the tendency to recurrences of ague. Ramazini relates 
the case of a patient harassed by an obstinate ague, and who 
was cured by mercurial frictions administered for syphilis. 
The influence of splenic disease in keeping up the morbid 
train of actions of the original fever, and in producing re- 
lapses, has been recorded by M. Piorry. In more than 500 
cases of ague in which he observed the state of the spleen, 
he comes to the following conclusions, namely : — that the 
organ is invariably enlarged during the progress of the fever, 
and that by the use of quinine the spleen diminishes in size ; 
that its reduction in size bears some relation to the quantity 
of quinine taken ; that the effect it produces upon the fever 
is in proportion to the reduction of the spleen ; that the dis- 
ease is cured simultaneously with the subsidence of the 
splenic enlargement ; and that the fever is apt to recur so 
long as the spleen exceeds its normal size. The treatment 
of the disease as to stages is to be managed as follows : — 



5 AGUE. 

During the cold stage the patient generally desires to be let 
alone, care being taken that he has abundance of bed-clothes. 
If the stage continues unusually long without signs of reaction 
the application of external warmth becomes necessary with 
warm drinks ; and even ammonia, ether, camphor, and other 
diffusible stimulants may be required if the vital powers are 
unequal to the development of reaction. During the hot 
stage, diluent drinks may be indulged in, if the patient de- 
sires them, with cooling diuretics ; but the danger consists 
in the approach of collapse when the sweating stage com- 
mences ; and when stimulants and support may be required. 
The first dose of quinine should, then, be given towards the 
close of the sweating stage. " I always assume," writes 
Professor Maclean, "that in first attacks the type of the dis- 
ease will prove to be quotidian, and take my measures ac- 
cordingly, making sure that the patient shall have thirty 
grains of quinine between the termination of one paroxysm 
and the hour when we may look for another ; and looking 
to the fact that we may look for the setting in of the cold 
stage, perhaps two hours earlier than on the first day, the 
last ter grain dose of quinine should be given so as to antici- 
pate that time by at least an hour." It is to be administered, 
in solution, dissolved by a small quantity of dilute sulphuric 
acid, and the dose mixed with syrup of orange peel. It may 
also be administered in starch or beef-tea enemata, or by 
subcutaneous injection. The object and action of quinine 
are to break the system off " the habit of going through the 
phenomena of an ' ague fit.' It counteracts the influence of 
the malarial poison, and prevents the repetition of the 
attacks. A moderate degree of cinchonism must still be 
maintained for some days, to the extent of ' ringing in the 
ears,' by giving three or four grains of quinine in solution 
every three or four hours, and a day or two before the 
interval of a month the patient must be again brought under 
the influence of this remedy. Within this period (a lunar 
month) there is always a tendency to the repetition of the 
' ague fit,' the habit of which must be thus broken ; other- 
wise it will be strengthened by every successive attack " 
(Maclean). Next to quinine in the cure of ague comes 
arsenic. From six to eight drops of Fowler's solution may be 
given during the interval of freedom from fever. It should 
be given in small doses, and not persevered in for more than 
eight or ten days ; and like quinine its use must be continued 
in diminished doses for some time after cessation of the 



ALBUMINURIA. ALCOHOLISM. 9 

fever. The earliest signs of its physiological action must be 
looked for to determine to what extent it muse be pushed — ■ 
these being redness of the eyes, watering of the mouth, and a 
silvery state of the tongue. The dose should always be 
given after food. In malarial brow-ache (brow-ague) and ma- 
larial hemicrania it is more efficacious than quinine. Due at- 
tention must be paid to feeding during the intermission, 
especially by beef-tea and farinaceous food. 

In all complications of ague, be they cerebral, pulmonic, 
hepatic, or gastric, quinine must still be the therapeutic agent 
to be relied upon. Antiphlogistic measures are not to be 
substituted in place of it on any account whatever. As to 
the malarious cachexia, removal from the malarious locality 
is the first essential condition to restoration of health ; the 
next is a combination of nutritious diet, abundance of exer- 
cise, pure air and pure water ; and clothing should be warm 
on first coming into cold latitudes. The prophylactic use of 
quinine must still be persevered in ; and if appetite fail, a 
course of syrup of the phosphate of iron, quinine and strych- 
nia in ten-minim doses, in a large quantity of water (a claret 
glassful), will be of service. In the experience amongst the 
invalided soldiers at the R. V. Hospital at Netley Dr. Mac- 
lean has found this medicine of much use. The chronic 
malaria cachexia is also much benefited by arsenic, especially 
when there is diarrhoea. In such cases two minims of 
Fowler's solution with five minims of laudanum should be 
given before meals. So also the use of coti bark may be of 
service in diarrhoea. In the treatment of the anaemic chlorosis 
of malaria arsenic is especially adapted to those cases in 
which iron does not agree ; while the efficacy of iron is often 
also increased by its combination with arsenic. 

Should the spleen continue of large size ointment of the 
bin-iodide of mercury is to be rubbed in over the gland. A 
portion about the size of a nutmeg is to be applied with a 
smooth spatula, the patient sitting before the heat of the fire, 
as long as he can bear the smarting which follows. The 
remedy has a not less beneficial influence on enlarged livers 
(Prof. W. C. Maclean). 

Albuminuria — See BrigJifs Disease. 

Alcoholism. — Definition. — A train of morbid phenomena 
produced by the slow and cumulative action of alcohol in the 
various forms in which it is used as a drink. Delirium is one 
of the most prominent features of the morbid state, which 
is otherwise characterized by hallucinations, dread, tremors of 



IO ALCOHOLISM. 

the tendons and muscles of the hands and limbs, watchfulness, 
absence of sleep, great frequency of pulse. A thick, creamy- 
fur loads the tongue, and a cool, humid, or perspiring surface 
prevails ; while the patient gives forth a peculiar odor, of 
a saccharo-alcoholic description; more or less strong. 

Treatment. — The indications are, — (i.) The elimination 
of the poison ; (2.) the sustenance of the patient during this 
period. The two most fatal errors which can be committed 
in the treatment of delirium tremens are to bleed the patient 
or to give him opiates. The greatest number of cases of 
those treated by opiates are apt to terminate by convulsions 
and coma (Morehead, Peddit, Law, Cahill, Laycock). 
If it be true, also, that opium and alcoholic stimulants singly 
are to be deprecated in the treatment of delirium tremens, a 
fortiori in their combination there is a twofold danger, 
alike in tropical as in temperate regions it is a course of 
treatment attended with much hazard, and if systematically 
followed, is certain of leading to unfortunate results (see 
Moreheads's "Researches on Diseases in India ;" also, 
" Notes on Treatment of Delirium Tremens," by W. Hanbury, 
33rd Regiment, in Madras Quarterly Journal, July, 1863). 
The strength must be supported by diet of the most nutri- 
tious hind, m a fluid and mild form, such as yolk of eggs, 
soups, and the like. Food should be given in small quanti- 
ties and often. Beef-tea, spiced soup, and egg-flip, are each 
to be commended at different periods of the day. If the pa- 
tient continues to digest food, the danger is much diminished, 
which in the first instance is from exhaustion. Careful 
nursing is above all things necessary, so that protection from 
all sources of danger may be adequate and the food ad- 
apted to the state of the digestion, which is always feeble. 
The disease must be treated as one spontaneously curable ; 
not by withholding remedies, but by using them in strict 
subordination to good nursing and carefully adjusted diet 
and regimen (Ware, Hood, Peddie, Laycock, W. T. Gaird- 
ner). Active specifics for delirium tremens appear to be 
founded on the idea that the disease is one nominally of 
high mortality. Hence the enormous doses of digitalis 
(Jones) and of Cayenne pepper (Kinnear and Lyons of 
Dublin) ; but before resorting to the use of such remedies 
as digitalis, it will at least be judicious practice to adopt 
such means as are calculated to restore the powers of nature 
— namely, nutrients and rest ; while the stimulus of such a 
spice as Cayenne pepper, given in the soup, on the atonic 



ALCOHOLISM. II 

stomach, will have a favorable influence on absorption. 
Under the care of my friend, Dr. Lyons, of Dublin, numer- 
ous cases of delirium tremens have rapidly yielded to capsi- 
cum, in doses of xx. to xxx. grains, in the form of a bolus. I 
have given it in numerous cases and in all forms of chronic 
alcoholism. Its influence in soothing the patient and in 
securing quiet sleep has been certainly remarkable. By 
some reviewers this influence has been questioned ; but the 
evidence of its good effects are daily accumulating. Dr. 
Ringer, in an able article in the Brit. Med. Journ., in 
187 1, advocates the use of capsicum, " given in doses of 
the tincture (five to ten drops) in a little syrup of orange 
peel. Or the powder may be formed into five-grain pills 
with extract of gentian — one to be taken every four hours 
till quietude is obtained ; or, twenty grains in a single dose 
may be taken before meals, or whenever depression or 
craving for alcohol arises." It induces sleep in the early 
stages of delirium tremens. It obviates the morning vomit- 
ing, removes the sinking at the pit of the stomach, the in- 
tense craving for stimulants, and promotes appetite and 
digestion. Dr. Wilks prescribes it with nitric acid and nux 
vomica. Dr. Lauder Brunton has given a great deal of at- 
tention to this subject, and, according to his experience, a 
combination of iron and nux vomica (say fifteen minims of 
the tincture of the perchloride and ten of tincture of nux 
vomica) is one of the most efficacious remedies for the tre- 
mors of chronic alcoholism. If the stomach be deranged, as it 
very frequently is, the indigestion should be treated previ- 
ously to the administration of iron, by giving ten grains of 
subnitrate or carbonate of bismuth with ten of magnesia, 
suspended with gum tragacanth. If there be any tendency 
to sleeplessness, or if the tremors should not rapidly disappear 
under the use of the iron and nux vomica alone, thirty or 
forty grains of bromide of potassium should be given at 
night. The chalybeate mixture already mentioned, either 
alone or with the addition of five or ten minims of tincture 
of capsicum, tends to alleviate the craving for drink, An- 
other mixture recommended for this purpose consists of 
sulphate of iron, magnesia, and oil of cloves : a third consists 
of carbonate of ammonia in infusion of gentian, to be taken 
whenever the craving is felt. Should the craving come on 
at intervals of several weeks, with complete intermissions 
between, the case should be treated like one of epilepsy, by 
the administration of bromide of potassium. 



12 ALCOHOLISM. 

Chloral is now a most important and valuable addition to 
our remedial agents in this disease. It produces sound and 
refreshing sleep, followed by relief to all the symptoms. It 
now seems to serve all the purposes intended by opium. 

The late Dr. Jones, of Jersey, gave as much as half-ounce 
doses of the tincture of digitalis till three doses had been 
taken ; and then, if excitement were not subdued, nor sleep 
induced, two fluid drachms were repeated every three or four 
hours (Med. Times and Gazette, Sept. 29, i860). But Dr. 
Ringer justly cautions against such excessive doses, and re- 
cords two instances in which the patient suddenly fell back 
dead. The disease no doubt proves suddenly fatal, some- 
times independently of any remedy ; but the powers of digi- 
talis in a tincture are much too uncertain to be relied upon 
as safe in such enormous doses. Bromide of potassium has 
been found of great use in calming the excitement of delirium 
and procuring sleep, especially in the earlier stages of the 
disease, before the delirium has become furious. The dose 
may be xx. or xxx. grains every two hours. Its good effects 
are, however, very uncertain when given alone ; less so when 
combined as suggested by Dr. Lauder Brunton (Ringer). 

In some cases purgative remedies are indicated from the 
first. " These cases are known by the flushed, bloated ap- 
pearance, the very foul tongue, the mawkish, peculiar odor of 
the breath, the fetid discharges from the bowels, and the his- 
tory of a recent surfeit of eating as well as drinking" (W T. 
Gairdner, "Clinical Medicine," p. 271). 

Opium maybe administered with safety and advantage only 
in protracted cases, provided the quantity given in twenty- 
four hours is never allowed to exceed the full dose which 
would be considered safe for a healthy person of the age and 
sex of the patient. Where it appears to be indicated in pro- 
tracted cases, it ought to be pushed as rapidly as possible for 
two or three doses, while its effects are carefully watched. 
Its use must be discontinued for at least a good many hours 
as soon as a full maximum amount of 3 iss. to 3 ii. of the 
tincture, in all, has been reached, or even sooner if the pupils 
have become contracted during its use. This remedy should 
always be given in the fluid form, otherwise it is apt to ac- 
cumulate in the bowels, owing to the weakened state of the 
digestion ; and a laxative, or even a purgative, should be al- 
ternated with opium, followed by a bitter tonic, which always 
operates favorably in lingering cases of nervous and dyspep- 
tic exhaustion. Narcotics are only safe in delirium tremens 



ALOPECIA AREATA. ANAEMIA. i$ 

when they are given with the object of aiding and seconding 
the natural cure of the disease, employed in moderate doses, 
and given only at the latter stages. The heroic use of them, 
as heretofore too often advocated by most eminent phy- 
sicians, is now recognized as a treatment which merely sub- 
stitutes narcotic poisoning for alcoholism or delirium tremens. 
Envelopment in a wet sheet, and then a blanket round the 
wet sheet, is recommended by Dr. Wilks and Niemeyer as a 
valuable sedative appliance. As soon as hot vapor so gener- 
ated surrounds the patient, he falls into a quieL sleep {Med. 
Times, Sept. 19, 1868). 

Alopecia Areata — See Tinea Decalvans. 

Anaemia. — Definition. — A disease in which there is 
either a relative diminution of the mass of blood (Andral), 
with the general composition and distribution of the blood 
altered from the normal standard ; or in which the mass of 
blood is diminished, and the liquor sanguinis is watery, poor 
in albumen, and containing an excess of salts. These con- 
ditions, co- existing with relative deficiency of the red blood- 
corpuscles (Vogel), and a diminution of the urine-pigment 
(Parkes), with altered innervation of the vascular system 
(Lebert), constitute anaemia. 

Treatment. — The energies of the physician must be directed 
to discover and counteract the cause of the anaemia. Nutri- 
tious substances must be supplied for diet, in the shape of 
easily digested meats and broths. The purely tonic treat- 
ment, in the combination of air, exercise and diet, must be 
carried out as far as practicable. A change of air is abso- 
lutely necessary, and generally also of diet. Iron is one of 
the best medicinal remedies ; and it ought to be taken as 
largely diluted with water as possible. The astringent pre- 
parations are pre-eminently tonic -, and are especially useful 
when the anaemia is associated with or dependent upon inor- 
dinate discharges. Solution of the perchloride of iron, in the 
form of tinctura ferri perchloridi, in doses of ten to thirty 
minims in water, or in an infusion of quassia, or of calumba, 
has properties in common with the numerous salts of iron, 
and is one of the most reliable preparations. If the anaemia 
is associated with diarrhoea, or menorrhagia, or leucorrhoea, 
the solution of the pernitrate of iron, in similar doses, is at- 
tended with benefit. A preparation which is no longer new 
to the pharmacopoeia — the syrup of the phosphate of iron — ■ 
possesses the general properties of the ferruginous compounds, 



14 AN7EM1A. 

and is of great service when the anaemia is associated with 
certain forms of dyspepsia, or with amenorrhcea. It invigor- 
ates and increases the powers of digestion, and may be given 
to the extent of one to three drachms for a dose in water. 
Another phosphatic preparation of very great value is that 
which was devised by the late Dr. Easton, Professor of Ma- 
teria Medica in the University of Glasgow. Although it is 
not in the pharmacopoeia, and although its mode of prepara- 
tion had not been published before Dr. Easton kindly sent 
it to me for publication in the previous editions of this work, 
yet the combination has become very popular throughout the 
country as a valuable tonic in anaemia and cachexiae generally. 
As such it has been largely used by my colleagues, Professors 
Maclean and Longmore, amongst the used-up cachectic and 
anaemic soldiers under treatment at the Royal Victoria Hos- 
pital at Netley ; and I would add my testimony to its being a 
most valuable medicine in general practice.* 

*The following is the original formula devised by Dr. Easton for the 
preparation of the phosphates of iron, quinine, and strychnia, in the form 
of a syrup ("Syrupos ferri, quiniae et strychnioe phosphatum ") : — .1$ 
Ferri Sulph. 3 v. ; Sodag Pliosph., 3 vi. (a little more phosphate of soda 
gives a better result, say § i.) ; Quinia? Sulph., grs. cxcii. ; Acid Sulph. 
Dil., q. s. ; Aqua? Ammonias, q. s. ; Strychniae, grs. vi.; Acid. Phosph. 
Dil. , | xiv. ; Sacchar. Alb., § xiv. " Dissolve the sulphate of iron in i 
oz. boiling water, and the phosphate of soda in 2 oz. boiling water. Mix 
the solutions, and wash the precipitated phosphate of iron till the wash- 
ings are tasteless. With sufficient diluted sulphuric acid dissolve the 
sulphate of quinia in 2 oz. water. Precipitate the quinia with ammomia 
water, and carefully wash it. Dissolve the phosphate of iron and the 
quinia thus obtained, as also the strychnia, in the dduted phosphoric acid; 
then add the sugar, and dissolve the whole, and mix without heat. The 
above syrup contains about one grain phosphate of iron, one grain phos- 
phate of quinia, and one thirty-second of a grain of phosphate of strych- 
nia in each drachm. The dose might therefore be a teaspoonful three 
times a day. The amount of phosphate of quinia might be increased ac- 
cording to circumstances ; and if eight grains of strychnia were employed 
in place of six, as in the above, the phosphate of strychnia would be in 
the proportion of the one twenty-fourth of a grain in every fluid drachm 
of the syrup. I would scarcely venture on a much larger dose. In cases 
of delicate children, with pale countenances and deficient appetites, I 
have given, with great benefit, a combination of equal parts of the above 
syrup and of that prepared by Mr. Edward Parrish, often called chemical 
food. To children between two and five years of age, the dose of this 
combination may be a teaspoonful three times daily. The preparation 
ought to be kept as much as possible from light and air, otherwise the 
preparation loses its characteristic opaline appearance, and assumes a 
fawn color; a precipitate may be thrown down." It is prepared by 
Messrs. Murdoch, Chemists, in Glasgow ; by Duncan and Flockhart in 
Edinburgh ; by Randall and Sons, Southampton ; and by Savory and 
Moore, in London. 



ANEMIA. 15 

In some cases the astringent preparations of iron are not 
suitable, and are apt to irritate delicate stomachs, or those in 
whom any inflammatory local disease exists. For delicate 
females and children the saccharated carbonate of iron is a 
most valuable preparation, in the form of mistura ferri com- 
posita to the extent of one to two ounces for a dose ; or in 
the form of the pillula ferri carbonatis, in doses of from five 
to twenty grains in the twenty-four hours. The citrate of 
irpn and ammonia is another remedy which possesses scarce- 
ly any astringency, and may often be given in cases of anaemia 
when the stomach will not bear more astringent preparations. 
Five to ten grains of this salt may be taken during the twenty- 
four hours. It is best taken during effervescence, pre- 
scribed in solution of citric acid, and not in bicarbonate of 
potash solution. If it is put into the latter, carbonic acid 
will be given off, and probably burst the bottle. Tincture of 
orange-peel is the best flavoring agent ; but as the salt will 
not dissolve in the tincture alone, it is necessary to dissolve 
the salt in water first, and then add the tincture, otherwise 
the division into doses is impracticable (Squire). When it 
is desirable to continue the use of iron for a long time, as in 
the anaemia of neuralgic affections or tic-douloureux, or to 
give it in large doses, the magnetic oxide of iron is the best 
preparation to administer in doses of five to twenty grains 
twice or thrice a day in water. The reduced iron — the fer- 
rum reductum of the British pharmacopoeia — is also a reme- 
dy which does not possess the astringent properties of the 
other preparations, and is one of the most powerful remedial 
agents in cases of anaemia. One to five grains may be given 
several times a day in powder or in pill. It has no taste, and 
one grain is equal medicinally to five grains of the citrate of 
iron. The citrate of iron and quinine, either in solution or 
in the form of a pill, is a new and useful preparation, in dose c 
of five to ten grains three times a day. 

Generally, such a preparation of iron must be found as 
will not check the digestion of other food. If loss of appe- 
tite and feverishness follow its use, the form of the remedy 
is probably unsuitable, and requires to be changed. Chlorine, 
in the form of warm hydrochloric acid baths, is highly spoken 
of by Dr. T. K. Chambers, as an agent of great value, and as 
a directly restorative medicine in anaemia (1. c, p. 332). The 
bowels are to be kept regular by four grains of the pills of 
aloes and myrrh taken at bedtime, Ferruginous remedies 
are always of use when we have reason to believe that there 



I 6 ANASARCA.' ANGINA PECTORIS. 

is a diminished energy in the formation of blood-cells ; and 
if the urine be pale and almost neutral during the whole of 
twenty-four hours, it is as good an indication for the use of 
iron as the pallor of the skin in cases af anaemia (Parkes). 
Dr. Trousseau was of opinion, however, that for anaemia, 
complicated with tubercles, iron preparations were unsuit- 
able, as tending to hasten their development. Dr. Clymer has 
found arsenic a valuable remedy combined in the form of 
chlorides of arsenic, iron, and quinine. 

Anasarca. — Definition. — An accumulation of serum in 
the areolar tissue throughout the body ; a general oedema or 
anasarca with effusion into one or more of the large serous 
cavities. 

Treatment of general dropsy is regulated by the nature of 
the disease which causes the dropsical state, and will be con- 
sidered under Heart Disease and Kidney Diseases. 

Angina Pectoris. — Definition. — Pain or spasm of a 
weakened heart (Chevers), referred to the lower part of the 
sternum, or to the praecordial region, extending through the 
chest to the left scapula, and up the sternum to the root of 
the neck. The pain is characterized by its suddenness, its 
severity, and by a sense of constriction or of burning. It 
compels the patient, if walking, instantly to stop, and almost 
prevents inspiration. The pain is felt likewise in the left 
shoulder, whence it sometimes reaches to the elbow, rarely 
to the hand, often with a sensation of numbness in the parts. 
A tendency to syncope exists, associated with intense anxiety, 
and a sensation of approaching dissolution. 

Treatment. — The indications are to be found in a study of 
the lesions on which the paroxysms mainly depend. Med- 
icine can do little more than mitigate the severity of an at- 
tack. This is generally best done by diffusible stimulants, 
such as brandy, ether, chloroform, ammonia, chlorodyne. Al- 
cohol, in small doses often repeated, sesqui-carbonate of am- 
monia, in doses of from three to five grains, the muriate of 
ammonia, in doses of from ten to twenty grains, have each 
powerful stimulant effects. Hot bottles and sinapisms 
should be applied to the feet. The bowels may require to 
be rapidly and efficiently acted upon. Thirty minims of 
tincture of digitalis, repeated at the end of half an hour, give 
great relief. It has also been beneficial when the angina was 
associated with fatty heart. In that form of angina pectoris 
where there is distension of the right ventricle, accompanied 



AORTA, ANEURISM OF. I 7 

by palpitation, dyspnoea, and lividity of the face (cardiac asth- 
ma), the frequent use of digitalis exercises a stimulating in- 
fluence on the sympathetic cardiac ganglia and muscular 
fibres (Fothergill). 

Aorta, Aneurism Of. — Definition. — A spontaneous cir- 
cumscribed partial dilatation of some portion of the aorta, , 
consequent on lesion or degeneration of its walls. 

Treatment. — Local bleeding is useful when there are pain 
and tenderness over the aneurismal sac. General blood-let- 
ting may be useful if the circulation is excited, and the pa- 
tient be of full habit, but not on the principle advocated by 
or ascribed to Valsalva. Of all remedies digitalis, aconite, 
belladonna and veratrin are the most useful in tranquillizing 
and regulating the action of the heart. The deposition of 
fibrine from the blood is more prone to take place when the 
circulation is " slowed." It is the principle of treatment in 
the cure of aneurisms by pressure. The current of blood is 
not entirely stopped, but is rendered more slow, so as to 
have an amount of stagnation of blood in the sac favoring 
the separation of fibrine and its coagulation. A diminution 
of from ten to fifteen pulsations of the heart in the minute 
will greatly tend to the filling of the sac with coagula (Ful- 
ler). The medicinal agents which tend to promote this result 
are, ergotine, gallic or tannic acids, tincture of steel, acetate 
of lead, and iodide of potassium. Mr. Joliffe Tufnell, of Dub- 
lin, has advocated the treatment of aneurisms of the thoracic 
and abdominal aorta on the principle here enunciated — 
namely, that of " slowing " the circulation. It consists of 
restricted diet and perfect rest in the horizontal position, for 
periods varying from eight to thirteen weeks, combined with 
the employment of such remedies as may be necessary for 
special ends. The horizontal posture must be strictly and 
absolutely maintained, in a light and cheerful airy room, into 
which the sun shines, and from which the patient may be 
able to have as cheerful a view as possible out of the window. 
The diet must be confined to three meals, served at regular 
intervals, and restricted to the following in kind and in 
amount :- — Breakfast — Two ounces of white bread and but- 
ter, with two ounces of milk or cocoa. Dinner — Three 
ounces of broiled or boiled meat, with three ounces of pota- 
toes or bread, and four ounces of water or light red wine. 
Supper — Two ounces of bread and butter, and two ounces of 
milk or tea. These diets should make, in the aggregate, ten 
ounces of solid and eight ounces of fluid in the twenty-four 



A 8 AORTA, ANEURISM OF. 

hours and no more. The object of the special diet is to main- 
tain life on as little food as possible, without inducing restless- 
ness, as in some irritable constitutions, but if such restless- 
ness should occur, a little more food may now and then be 
allowed. Anodynes, aperients, narcotics, sedatives, and tonics 
are also useful aids in the management of the case. Of 
anodynes lactucarium is the most valuable, given in the form 
of a pill, by itself or combined with humulin and hyoscyamus 
{Med. Rep. Army Med. Dep., 1862, p. 472). The patient 
must avoid everything which tends to increase the action of 
the heart. Moderate living, without the plethora of excess, 
but with sufficient nutrition to maintain the circulation at a 
uniform flow, is the point to aim at. Fatal results may 
speedily follow any marked change of diet and regimen (Cop- 
land). Pain and depression will generally be subdued by 
the hypodermic injection of morphia, commencing with one- 
fourth of a grain. Cough is to be relieved by sedatives and 
expectorants. Dyspnoea may require tracheotomy Dropsy, 
may be lessened by mercury, digitalis, squills, juniper, and 
decoction of broom-tops. 

Since 1861, the following three special modes of treating 
aneurisms have been proposed, besides Mr. Tufnell's dietetic 
method : — (1.) The introduction of a quantity of fine iron 
wire into the aneurismal cavity, with the intention of supply- 
ing an extensive surface over which fibrine may coagulate. 
The late Dr. Murchison and Mr. Charles H. Moore practised 
this method in a case of saccular aneurism of the ascending 
aorta projecting through the anterior wall of the left side of 
the chest. Twenty-six yards of wire were passed through a 
small canula inserted into the tumor when it was evident 
that the patient could not live many days. With some modi- 
fications it was shown that the experiment might be justifia- 
ble in some cases of sacculated aneurisms only (Med.-Chir. 
Trans., Vol. XLVIL, p. 129, London, 1864). (2.) The 
method of rapid pressure treatment, as practised by Dr. 
William Murray, of Newcastle-upon-Tyne, and Lecturer on 
Physiology in the University of Durham. It has been ap- 
plied to aneurisms of the abdominal aorta. The cure by 
this method takes place rather by the coagulation of blood 
in the sac from sudden cessation of the current, than to any 
deposit of fibrine. The patient requires to be completely 
under the influence of chloroform, so that he may suffer the 
application of a powerful pressing instrument on sedative 
parts, and so as to restrain all muscular movement. All 



APOPLEXY. 19 

movement of the blood in the sac must be completely arrest" 
ed, and maintained in a motionless state, as in the applica- 
tion of a ligature to the vessel for aneurism. The duration 
of the treatment and maintenance of pressure can only be 
measured by the result as to the time when pulsation ceases 
in the tumor. The first condition of success is, that complete 
arrest of circulation in the tumor must be steadily maintained. 
Irregular pressure for ten hours has been known to fail. Con- 
solidation has occurred in twenty minutes in a case of Dr. 
Heath's, of Sunderland, when complete and steady pressure 
was maintained, having failed in a first trial with irregular 
pressure. (3.) Dr. Roberts, of Manchester, and Dr. G. W. 
Balfour, of Edinburgh, have each collected cases, some 
of them under their own care, in which the treatment 
of aneurism of the aorta by iodide of potassium was persist- 
ently carried out with remarkable beneficial results. The 
dose varied from five, seven, ten, fifteen, and twenty to thirty 
grains three times a day ; and the relief of pain, one of the 
earliest symptoms of amendment, does not follow till an effi- 
cient dose has been taken. It is better to begin with twenty 
or thirty grain doses at once, and intermit or suspend them 
for a day or two, if circumstances indicate the necessity of 
such step. The object is to saturate the system with the 
drug as speedily as possible. It is believed to owe its cura- 
tive agency to its power of increasing the coagulability of the 
blood. - A few weeks may be sufficient to bring about the 
curative result ; but Dr. Balfour's experience is, that any 
considerable amendment can only be procured by keeping 
the patient for many months, perhaps twelve or more, per- 
sistently saturated with the drug. (Balfour, Edin. Med. 
Joum., July, 1868, p. 33 ; Chuckerbutty, in Brit.. Med. 
Joum., July 19 and 26, 1862 ; Roberts, Brit. Med. Joum., 
January, 1863). The strict enforcement of the recumbent 
position is an adjuvant of paramount necessity in the treat- 
ment of all aneurisms. Tracheotomy may prolong life in 
some cases where stridor exists, if the laryngeal symptoms 
are the source of immediate danger (W. T. Gairdner). 

Apoplexy. — Definition. — Hemorrhages within the skull 
or spinal canal, consequent on the rupture of blood-vessels 
in the membranes or substance of the cerebro-spinal nervous 
system. 

Ireatment. — It may "incline the balance to recovery or 
death." Bleeding from the veins of the arm, the jugular 
vein, or the temporal artery, has been the most conspicuous 



20 APOPLEXY. 

method of treatment from the earliest times. It is now em- 
ployed only under the following circumstances: (i.) When 
there is an obvious increase of intracranial pressure, it is 
practiced so as to bring about indirectly a diminution of arte- 
rial tension. With such intracranial pressure there is cerebral 
hypersemia, and when a paralysis of the respiratory or vagus 
centre is threatened, then it is that venesection by diminish- 
ing this pressure may have the effect of prolonging life. 
Patients have thus been roused from a state of coma. Clin- 
ically, the indications for venesection under. such conditions in 
cerebral hemorrhage are: A turgid face with distended veins, 
and increased pulsation of the carotids; a powerfully acting 
heart; the radial artery of normal tension; the pulse of nor- 
mal frequency, or slow and regular; when the respiration is 
uniform, but of snorting character; when the patient is strong 
and not too old. Slow and deep respiratory movements, 
with stertor (indicating paralysis of the respiratory centre), 
and combined with rapid pulse (indicating paralysis of the 
vagus), add greatly to the necessity of immediate venesec- 
tion. The beneficial action of the remedy is shown by the 
pulse becoming softer, more subdued, and more regular. 
Venesection is out of place in all cases which do not corre- 
spond to this description (Nothnagel). Large bleedings are 
to be avoided. The blood ought to be permitted to flow 
from a large opening, in order more rapidly to relieve the 
congestion, to check, if possible, further effusion of blood, 
and to divert its active flow from the head. The head and 
shoulders should be raised while the blood is flowing. 

On the other hand, in some cases, bleeding during an 
apoplectic fit hastens a fatal result — collapse occurring during 
or immediately after venesection, from which the patient 
never recovers. It is to be avoided in the old and decrepit, 
where marked arterio-sclerosis is present; also if the pulse be 
small and slow, feeble, or almost imperceptible, the skin cold 
and clammy, with a tendency to death by syncope; if the 
heart's action be feeble or weak, and the pulse irregular; if 
the patient, has been of intemperate habits, or is suffering 
from organic disease of the heart and arteries; or if there is 
a gouty or rheumatic history, no advantage is to be gained 
by the abstraction of blood at this time and in this way. 
Blood-letting is therefore absolutely contra-indicated under 
the following circumstances: (a.) anaemia, (/>.) aortic valvu- 
lar disease, (<:.) in cases commencing with syncope. In such 
cases the use of stimulants must be had recourse to in order 



APOPLEXY. 21 

to prevent paralysis of the heart. The clinical indications 
for stimulants are: A pale collapsed expression of face, ab- 
sence of venous turgidity, slight arterial tension, heart's im- 
pulse weak, respiration hesitating and intermittent. It may, 
in some exceptional cases, be necessary to follow or combine 
venesection with stimulants. The stimulant agents may be 
(i.) Such as will rouse the depressed activity of the respira- 
tory centre, — e. g., sudden sprinkling of the skin with cold 
water; the application of ammonia to the nostrils; (2.) sub- 
stances which will stimulate directly the heart's action- — e.g., 
musk, strong coffee, wine, and preparations of ammonia. If 
the patient cannot swallow, enemata of musk may be used 
(Nothnagel). Many still believe with Trousseau, that in all 
cases; grave or slight, patients do better without either blood- 
letting or purgatives. He considers the part played by con- 
gestion of the brain to have been, much exaggerated. Dr. 
Althaus, also, is of opinion (after an experience of more than 
400 cases of hemiplegia from cerebral hemorrhage) that the 
former universal treatment by venesection was thoroughly 
irrational: and he considers that the condition of the brain 
during cerebral hemorrhage is not one of congestion (as was 
formerly believed), but is one of anosmia; that the organ not 
only loses blood largely, but is also, through compression 
from the clot, unable to receive a fresh supply; that death 
takes place chiefly from anaemia; and that by venesection 
we hasten the fatal result. Instead of doing nothing, how- 
ever, he recommends ergotine to be at once injected hypoder- 
mically (a grain of Bon jean's ergotine every hour, or even 
every half hour), into the subcutaneous areolar tissue. Ad- 
ditional chances of recovery may be given by applying to 
the head cold cloths, or crushed ice in a bladder, and mus- 
tard cataplasms to the feet; also, by placing a drop or two of 
croton-oil on the tongue, and by throwing up a cathartic 
enema of castor oil and turpentine. 

After the patient has in some degree revived, some time 
should be allowed for the absorption of the blood effused be- 
fore deciding upon the future treatment. A few hours hav- 
ing elapsed, the conduct of the practitioner should be guided 
by the occurrence -or not in the patient of pain of the head, 
which may be taken as a measure of the fullness of the brain, 
and its tendency to inflammation; but the less that is done dur- 
ing the first three or four days the better. If pain in the head 
continue, ten to twelve leeches should be applied from time to 
time, till that symptom is entirely relieved; or, supposing the 



22 APOPLEXY. 

pulse to be full and strong, and the patient free from head- 
ache, yet, under these circumstances, leeches should be ap- 
plied to the head, to subdue that reaction which so generally 
takes place from the fourth to the seventh day. The further 
treatment of the case is by moderately purging the patient, 
both as a means of relieving the head and of improving the 
secretions of the alimentary canal, which are often black and 
fetid. Active and searching purgatives generally do good at 
this stage. Five grains of calomel with a drachm of com- 
pound jalap powder, given as soon as the patient can swallow, 
and followed up by black draught, or by an ounce of sulphate 
of magnesia with camphor mixture every four or six hours, 
and continued, according to its effects, for a greater or less 
length of time, are the best means we have for promoting re- 
covery, and for preventing a relapse. In cases of hypertro- 
phy of the heart, without valvular disease, eight to ten 
minims of digitalis may be added to each dose of the purga- 
tive medicine. If the power of swallowing is in abeyance, 
then three or four drops of croton oil, with five grains of cab 
omel, rubbed up with fresh butter, should be put on the back 
part of the tongue, and stimulating enemata thrown up the 
rectum. The following are recommended by the late Dr. 
Tanner: 

1. Enema of Turpentine and Castor-Oil. — r>. Olei Ricini, 
Olei Terebinthine, a a § iss. ; Tincture Asafcetidae, § ii. ; 
Decocti Avense, § xii. ; misce, fiat enema. To be thrown up 
the rectum by means of a long stomach-pump tube. 

2. Croton Oil Enema. — L). Olei Ricini, Olei Terebinthinae, 
a a 3 i., Olei Crotonis, m vi., Decocti Avenae, fiv. : misce, 
fiat enema. 

Although turpentine is objected to by some on account of 
the intoxicating effects which it is sometimes apt to produce, 
it is nevertheless an efficient remedy where torpor and insen- 
sibility exist. It is of great importance to empty the rectum 
and lower bowel. 

If the intestines are distended by gases, an enema of castor 
oil and rue may be given: 

3. Castor Oil a?id Rue Enema. — 1>. Confectionis Rutae, 
3 i. ; Olei Ricini, § i.; Tincturae Asafcetidae, 3 ii- ; Decocti 

Avenae, § vii ; misce (Practice of Medicine, 4th edition, p. 

6 53)- 

Apprehension of a relapse being at an end, the patient is 
in general most willing to believe that the palsy which may 
remain is a mere local disease, and to submit to any treat- 



ARTERITIS. ASCITES. 23 

ment for its removal; but every attempt to act locally on the 
muscular system is prejudicial so long as any central irrita- 
tation exists. Such remedies are neither theoretically nor 
practically useful. (See "Paralysis.") Active or passive 
exercise of the muscles are remedies highly beneficial. The 
induced current of electricity is also beneficial. It seems to 
improve the nutrition of the paralyzed muscles, which tend 
to atrophy from long disuse, and paralysis tends also to get 
worse from diminished excitability of the nerves. Local 
faradization by induced currents of electricity gives artificial 
exercise to these muscles, and thereby improves their func- 
tional and nutritive properties. 

Dietetic and Prophylactic Treatment. — The diet of the pa- 
tient should be limited to milk, boiled vegetables, light pud- 
dings, and fish. At no subsequent period ought he to in- 
dulge in a full animal diet, or to drink undiluted wines. At 
the same time, too lowering a regimen is to be avoided, as 
thereby the irritability of the system and the heart's action 
generally is increased. All the causes of the disease already 
fully referred to should be avoided, counteracted, or over- 
come. The diet and the bowels should be carefully regu- 
lated, and the patient placed under the best possible hygienic 
influences. A sojourn at the moderately warm waters of 
Wildbad, Pfaffers, Ragatz, and Laudeck (Teplitz with great 
caution), and Rehme and Nauhein, are recommended by 
Niemeyer and Nothnagel, with careful regulation of diet and 
exercise. 

Arteritis. — Definition. — Inflammation oi the textures of 
an artery. 

Treatment. — Leeches should be applied freely over the 
course of the vessel ; and large doses of opium, or of ether 
with chloroform, may be given to relieve pain and dyspnoea. 
Iodide of potassium or colchicum may also be indicated, ac- 
cording to the constitutional morbid condition which has 
brought about the lesion. 

Arthritis, Rheumatic — See Ostec Arthritis, Chronic- 

Ascites. — Definition. — A collection of serum slowly ef- 
fused into the cavity of the peritoneum. 

Treatment. — When ascites occurs without any obvious 
organic cause, and without albumen in the urine, the best 
remedy is the bitartrate of potash, administered in divided 
doses, as one drachm three times a day, or every six hours ; 
or in one large dose, as half an ounce, combined, if the 



24 ASCITES. 

paitient's bowels be confined, with ten to fifteen grains of 
jalap. When the smaller doses are used, it may be useful to 
add ten grains of the citrate or tartrate of iron to each dose. 
If these remedies should fail, one-sixth to a half a grain of 
the extract of elaterium every night, or every other night, may 
be given. When ascites is combined with anasarca, squills 
afford most relief. Five to eight grains of the pulvis scillae, 
three times a day, generally relieve the dropsy. If the 
stomach be irritable, half a grain of opium should be added 
to each dose. When the ascites arises from disease of the 
heart, the kidneys being sound, and the urine free from albu- 
men, the treatment must have reference to the nature of the 
cardiac lesion. If the valves of the heart are diseased, the 
patient may be greatly relieved by the administration of 
tonics, stimulants, and saline or drastic purgatives. An 
ounce and a half of camphor mixture, with a drachm of the 
spirit of nitrous ether, fifteen minims of the tincture of hyoscy- 
amus, and a drachm of the sulphate of magnesia will form a 
draught which, taken three times a day, may greatly reduce 
the , dropsy. The tincture of squills (mx. to mxx.), with a 
drachm of the acetate of potash, has occasionally succeeded. 
Small doses of elaterium, as one-eighth to one-fourth of a 
grain three times a day, is a medicine that 16 also sometimes 
useful. Should the liver be inflamed or hypertrophied, with- 
out other alterations of structure, the dropsy may disappear 
with the cure of the hepatic disease. Bleeding by leeches, 
if the hepatic lesion be due to the congestion of inflamma- 
tion, and the neutral salts, such as the sulphates of magnesia or 
soda, or moderate doses of calomel, may give relief. If due 
to a cirrhotic liver paracentesis abdominis ought to be re- 
peated as a systematic method of treatment (F. T. Roberts). 
Abdominal pains are relieved most effectually by fomenta- 
tions. The bowels are often greatly constipated, and require 
drastic purgatives, as the black draught, castor or croton oil, 
or even elaterium. In ascites depending on enlarged spleen 
when it is simply hypertrophied, the bromide of potash, and 
the iodide of potassium, in doses of five to eight grains three 
times a day, have been found useful. My friend and col- 
league, Professor Maclean, has found that rubbing the binio- 
dide of mercury, in the form of an ointment, in the proportion 
of 15 grains of thebiniodide to one ounce of lard or vaseline, 
on the skin over the enlarged spleen, has a marked bene- 
ficial effect in reducing the enlargement. The ointment, in a 
piece about as large ac a nutmeg, is to be rubbed into the skin 



ASTHMA, HAY. ASTHMA, SPASMODIC. 25 

while the patient sits before a strong fire or in the rays of an 
Indian sun ; in the evening of the same day, half the amount 
is to be rubbed in lightly ; and the ointment is not to be re- 
peated at a less interval than 14 days. The invalided sol- 
diers suffering from splenic enlargement invariably ask for a 
supply of the remedy when they go from hospital. The 
biniodide of mercury, similarly used, has been of great service 
in reducing the swelling of a goitre. The dropsy which oc- 
curs in young chlorotic women, in whom the urine contains 
albumen (the kidney being healthy in structure though dis- 
ordered in function), is generally curable, — the most efficient 
remedy is the bitartrate of potash in drachm doses three 
times a day, combined with iron. 

Asthma j Hay. — Definition. — A peculiar catharral affec- 
tion occurring during the summer months, especially during 
the inflorescence of the grasses, or during the drying and 
conversion of the newly-mown grass into hay in May, June, 
and July. 

Treatment. — Regarding it as the result of irritation (speci- 
fic or mechanical) from fine particles of matter (indefinite 
dust or specific powder) floating in the air, the use of a res- 
pirator of fine cotton, or of crape or cambric in several folds, 
should prevent the affection, and ought to be tried by those 
who suffer every year about the months of May and June. 
In other respects the local catarrh must be treated as de- 
scribed under " Bronchial Catarrh," and " Bronchitis." 

Asthma, Spasmodic. — Definition. — A disease which 
culminates in paroxysmal attacks of difficult breathing, of 
varying duration. The dyspnoea seems to be immediately 
dependent on more or less extensive contraction of the small- 
er bronchi, due to spasm of their circular fibres. The breath- 
ing is accompanied by a wheezing sound, a sense of constric- 
tion in the thorax, great anxieties, and a difficult cough. The 
attack usually terminates by the expectoration of a quantity 
of mucus from the lungs, which varies considerably in ap- 
pearance and in amount. In some instances the mucus is 
thick and heavy, in others it is light and frothy, whilst in the 
severer forms there may be only a few dark pellets coughed 
up before relief is obtained (Pridham). In the hours imme- 
diately succeeding the fit, a remarkable diminution of the 
urea and chloride of sodium may occur, which would imply 
a considerable arrest either of formation or elimination, 
probably the former (Ringer, Parkes) ; or to the starvation 
that is generally enforced at that time (Salter). 



26 ASTHMA, SPASMODIC. 

Treatment comprises, (i.) What should be done during 
the fit ; and, (2.) during the intervals. When a patient is la- 
boring under a fit of either form of asthma, to tranquillize 
his suffering and shorten the attack is the aim of treatment. 
Any exciting case must be removed. An undigested meal, 
or constipation, must be got rid of — by an emetic in one case, 
or by an enema in the other. The patient should have a strictly 
tonic regimen ; and camphor mixture, to the extent of about 
an ounce and a half, combined with a drachm of the spirits of 
nitrous ether and some morphia, may be given every hour, or 
every two hours, for a short time. Some milder narcotic may 
be substitued for morphia, as tincture of hyocyamus, to the 
extent of about fifteen drops for each dose. Or asafcetida, 
castor, musk, or hydrocyanic acid, to the extent of miij. every 
six hours, may be substituted. If the fit should occur after 
a hearty meal, and after an emetic has been given, the tinc- 
ture of rhubarb, or the sulphate of magnesia, should be con- 
tinued in repeated small doses. If the attack be long, arrow- 
root or sago, with small quantities of wine or brandy, should 
be given to support the patient under his exhausting suffer- 
ings. Ipecacuanha, tartar emetic and tobacco are the drugs 
which most rapidly relax spasm as direct depressants. There 
is, however, great danger in the use of the latter, from un- 
manageable and dangerous collapse. Tobacco ought never 
to be indulged in by the asthmatic, except as an agent in the 
cure of his disease. Then only can he look to it for relief, 
and it should be smoked from a pipe. Ipecacuanha ought to 
be given in a dose of twenty grains at the onset of the parox- 
ysm. The feelings of the sufferer should be consulted as to 
the temperature to which he should be exposed during the 
paroxysm. Where there is any organic lesion the fresh air 
is grateful and reviving. On the contrary, when the parox- 
ysm is purely a spasm of the bronchial tubes, warmth, by 
relaxing spasm at their ultimate divisions, is generally more 
useful than cold. Patients learn by experience what will 
give them most relief. Strong coffee, spirits and water, ice 
rapidly swallowed, may suit individual cases. 

The treatment during the interval is all-important. Few 
cases will be found of true spasmodic asthma which are not 
entirely under the control of well-regulated dietetic manage- 
ment. By many physicians a rule of life as to diet is the only 
certain treatment of asthma. Extremely strict dietetic treat- 
ment and sedatives during the intervals of the paroxysms 
must be prescribed. A plan of treatment somewhat as follows 



ASTHMA, SPASMODIC. 27 

may be laid down, after that suggested by Mr. Pridham of 
Bideford and Dr. Hyde Salter of London : — The secretions 
from the bowels are first to be corrected by Pilulae Aloes cum 
Myrrha, gr. iii. ; Pilulse Hydrargyri, gr. i. ; Extracti Tar- 
axaci gr. ii.; Extracti Strammonii, gr. ss., made into two pills 
to be taken at bedtime, followed by a saline aperient in the 
morning. Or giving, every alternate night, Pil. Hyd., gr. iv.; 
Pulv. Ipecac, gr. i., in the form of a pill. And on the fol- 
lowing morning, Mist. Sennae comp., 3 i. ; Bicarbonatis Mag- 
nesia, gr. x. ; Bicarbonatis Sodae, gr. viii. ; and during the 
day small doses of compound rhubarb powder. After thus 
attending to the general secretions for about ten days, a strict 
diet is to be commenced, which must be regularly weighed 
out and adhered to, the hours of meals being fixed. (1.) 
Breakfast at eight a. m., to consist of half a pint of green tea 
or coffee, with a little cream, and two ounces of dry stale 
bread. Dr. Salter allows an egg or {not and) a mutton chop, 
or some cold chicken or game. Tea is better than coffee, 
and milk and water better than either. (2.) Dinner at one 
p. m., to consist of two ounces of fresh mutton, without fat c r 
skin, and two ounces of dry stale bread or well-boiled rice. 
Beef and lamb should be rarely eaten, pork or veal never. 
There should be no cheese and no dessert (Salter). Three 
hours after dinner (not sooner) half a pint of weak brandy 
and water, or whisky and water, or dry sherry and water, 
may be taken, or toast-water ad libitum. Water is the best 
fluid to drink. (3.) Supper at seven P. m., to consist of two 
ounces of meat as before, with two ounces of dry stale bread. 
The patient is not to be allowed to drink any fluid whatever 
within one hour before his dinner or supper, and not until 
three hours after either of these meals. At other times he is 
not limited as to drinks, otherwise than that all malt liquors 
are to be prohibited. Soda or seltzer-water may be indulged 
in when thirsty. With this dietetic treatment, sedatives, such 
as three grains of the extract of conium, are to be taken four 
times a day — namely, at the hours of seven, twelve, five, and 
ten, — the dose to be gradually increased to five grains four 
times a day. To each of these pills a fourth of a grain of 
the Extract of Indian hemp may be added, which may be 
gradually increased to one grain in each dose. Under this 
treatment in a few days distressing symptoms subside ; and 
after the regimen has been strictly persevered in for at least 
a month, two ounces more of meat may be permitted, if di- 
gestion is sufficient. The stools must be repeatedly seen by 



28 ASTHMA, SPASMODIC 

the physician ; and the stomach must not have more to do 
than it can accomplish. The powers of digestion are known 
to be recovering when there is a craving for food as the hour 
of nourishment arrives. . If flesh is gained, strength improves ; 
and while the tongue cleans, the appetite improves, the dis- 
tension of the stomach lessens, and the powers of digestion 
recover. The patient ought to be able to sleep six or seven 
hours at a time, and to lie in bed all night. If these results 
follow, the ultimate cure of the disease may be looked for ; 
but it may at the same time be taken for granted that the 
asthmatic can never with impunity eat and drink as other 
people. It is only by the exercise of self-denial that the pa- 
tient has it in his own power to live a life of comparative 
ease and comfort. Many patients not possessed of such re- 
solution, self-denial, and strength of mind, will say such 
dieting does not suit their constitution, and that they cannot 
or will not persevere ; but no trial of the remedy can be con- 
considered sufficient which does not embrace a period of at 
least six months, the physician taking care to ascertain the 
weight of the patient, his age and height, before commencing 
any treatment. It is difficult to persuade many people to live 
so abstemiously. Many cannot control their appetite ; or 
they believe that in so limiting themselves in regard to diet 
they will injure their constitution. It is necessary to subdue 
by sedatives rather than opiates the abnormal ravenousness 
of appetite. Asthmatics are generally dyspeptics ; and the 
most simple rule regarding diet is : — Let no food be taken 
after such a time in the day as will allow digestion being 
completed or the stomach empty before going to bed. The 
time when the last solid food should be taken will depend 
upon what the bedtime is. If ten, or half-past, then three or 
four should be the dinner hour, after which no more solid 
food should be eaten. 

Open air exercise must be freely taken, but not within 
three hours after eating animal food, and the exercise must 
be always short of fatigue. The greatest punctuality is 
necessary as regards the taking of food, of exercise, and of 
medicine ; and the bowels should act immediately after 
breakfast, either naturally or by enema. Success depends 
on the regularity with which all the functions of the body 
can be performed ; and care should be taken to rest body 
and mind, at least, for one hour after food. Smoking stra- 
monium, the inhalation of chloroform, or of ether, or both, al- 
though they appear to soothe and mitigate the paroxysm in 



ASTHMA, SPASMODIC. 29 

some cases, yet they do not appear to shorten the attack in 
any. The inhalation of nitrite of amyl has been recently recom- 
mended. The fumes of stramonium are to be collected in an in- 
verted glass bowl with a narrow mouth.The bowl being charged 
to its full, is placed under the mouth of the patient, who is 
directed to inhale, to the fullest extent in his power, the 
smoke which has been collected in the bowl. Or the stra- 
monium may be smoked like tobacco, " then puff the smoke 
into a tumbler, and inhale it cold into the lungs " (Bullar). 
Or it may be smoked as an Oriental smokes the hookah, in 
which the smoke is purified by being passed through water. 
Cigars and cigarettes of stramonium are now sold by the 
chemists. The fumes of brown paper saturated with a solu- 
tion of nitrate of potash sometimes also relieve the spasms. 
Indian hemp, in doses of from two to four grains of the ex- 
tract, or thirty minims of the tincture, will often relieve the 
spasm for the time being, but may fail ever after, (See Wat- 
son, " Lectures on the Practice of Physic," Vol. II). 

Only one remedy — jaborandi, and its alkaloid pilocarpin — ■ 
has been found not only to remove the urgent symptoms of 
asthma, but to exercise, at the same time, a favorable influ- 
ence on the disease itself. It produces a powerful revolution 
in the distribution of the blood, by attracting a large volume 
to the skin and salivary glands ; and by diminishing its vol- 
ume through copious perspiration and salivation, congested 
internal organs are relieved in a proportional degree. Dr. 
Berkhart has found the alkaloid preferable to jaborandi, be- 
cause — (1.) It acts more rapidly; (2.) it does not produce 
strangury ; (3.) the dose can be more accurately regulated. 
In cases where the cardiac muscles are in a state of fatty 
degeneration, the influence of pilocarpin may induce the 
most alarming symptoms; which soon spontaneously subside, 
the heart regaining its previous force. But if it lingered to 
do so, a subcutaneous injection of -^\-q or -fa grain of atropine, 
or one drop of liquor atropise (B. P.), immediately restores 
the balance. Pilocarpin, or muriate of pilocarpin, is more 
suitable in the treatment of the younger asthmatics, but is by 
no means contra-indicated in patients of more advanced age. 
The dose should not exceed one-third of a grain. Dr. Berk- 
hart has never used more than ten drops of a 2 per cent, so- 
lution, injected under the skin of either arm. During the 
action of the drug, the patient should preserve the recumbent 
posture — which the almost immediate relief obtained will 
enable him to do — and he should be carefully watched until 



30 ATHETOSIS. -BERI-BERI. 

the effect has passed off. It is desirable to have a solution 
of atropine or liquor atropine always at hand, in case of need. 
It is well, also, not to use pilocarpin soon after the patient's 
meals ; if the dyspnceal seizure occur under these circum- 
stances, there are, it is needless to say, other remedies more 
suitable {Brit. Med. Journal, June 19, 1880). Similar re- 
sults may be obtained in less urgent cases by the internal 
administration of the powder of the leaves, in doses of 30 to 
90 grains, infused in boiling water — the water and grounds 
being swallowed together. 

Athetosis. — Definition. — A form of spasm hitherto ob- 
served chiefly in the muscles of the hand and of the fore- 
arm, characterized by the impossibility which the patients 
find in keeping the fingers and toes in any desired position ; 
and the inability to prevent a continuous action of them, 
which is slow, regular, and never ceasing, except when the 
limb is supported, or during sleep. The movements are not 
disorderly, like hysteria and chorea, nor tremulous, like those 
of paralysis agitans and various forms of sclerosis. 

Treatment. — Beyond improving the general health, any 
medicinal treatment can only be determined upon by a spe- 
cial study of each particular case. If syphilis has been an 
antecedent, its appropriate remedies must be had recourse to. 

Beri-Beri. — Definition. — A constitutional disease, expres- 
sed in the first instance by anaemia, and culminating in acute 
oedema. It is marked by stiffness of the limbs, numbness, 
and sometimes by paralysis of the lower extremities, op- 
pressed breathing (anxietas in paroxysm), and a swollen and 
bloated countenance. The urine is secreted in diminished 
quantity. The oedema is general, not only throughout the 
connective tissue of the muscles, but throughout the connec- 
tive tissue of solid and visceral organs in every cavity of the 
body. Effusion of serum into the serous cavities very gen- 
erally precedes death. 

Treatment. — Bleeding has been considered applicable to 
those cases where there is extreme difficulty of breathing and 
delirium, when the patient is robust, and when the oedema 
does not pit much on pressure, where there is rapid and full 
pulsation of the large arteries, and if the urine shows the 
existence of albumen (Wright) ; but, judging from the 
pathology of this disease, the constitutional influence of 
stimu ants, of a generous strengthening diet, of tonics, diu- 
retics and analeptics, ought undoubtedly to be the basis of 



BERI-BERI. 3T 

treatment. Should there be irritability of the stomach, an 
effervescing draught, with doses of laudanum and camphor 
mixture are useful. Saline drinks should be administered, 
and the extremities should be rubbed with stimulating lini- 
ments, and rolled in flannel bandages. In the asthenic or 
chronic form of the disease, the strength must be supported 
by the most nourishing diet that can be given in small bulk, 
aided by tonics, and wine if necessary ; while doses of equal 
quantities of squill and digitalis (ten to fifteen drops of each) 
may be given twice or thrice daily. In the third and mildest 
form, a native remedy called Treeak Farook is very useful. 
The ingredients of this medicine are unknown ; but it pro- 
fesses to be the " Theriaca Andromachi " of old writers. It 
is prepared in Venice, and transmitted to India through 
Arabia, and was first recommended by Dr. Herklotts, of the 
Madras Presidency, as a remedy in beri-beri. It is a thick 
extract (in which some terebinthine material largely enters), 
which is only to be procured from the Moghuls, and in those 
towns which still keep up some communication with the 
Arabian Sea. Many observers bear testimony to its good 
effects in removing the oedema and subduing the pulse 
(Wright, Traill, Madras Quarterly Med. Jour., 1842, Vol. 
IV., p. 154, Geddes, Malcolmson). In some recorded cases 
the pulse has fallen in four days from 108 to 84 beats per 
minute under its use. The prescription most approved of 
consists of pills of the following ingredients : — 

1^. Treeak Farook, 3 ss. ; Pulv. KJiei., 3 iiss ; Confectio. 
Aromat, 3 ss. ; Mellis, q. s., misce, et divide in pill xlviii. 
(Malcolmson). 

The electuary form is also much used in India. The 
remedy does not seem to be an active medicine, except in 
combination. Four or five stools are obtained daily under 
its use, and its action is not accompanied by any violent 
purging, increase of pulse, or determination to the surface ; 
and after it has been used from one to two weeks, the oede- 
ma generally disappears, when the numbness and paralysis 
subside. If it purges, the quantity of rhubarb must be 
diminished. The patient should feed on animal food, 
wheaten cakes, and milk. In instances where the native 
remedy has failed to produce a beneficial effect, mix vomica 
has been more successful, commencing with doses of two 
grains of the extract daily, and increasing the dose gradually 
according to the physiological result. The extract of nux 
vomica, in doses of half or a quarter of a grain, combined with 



32 BLADDER, CATARRH OF. BRAIN, TUMORS, ETC. 

iron or gentian in a pill, is the most convenient form. Local 
abstractions of blood from the spine have also proved useful ; 
and a blister applied over the loins has given relief in many 
obstinate cases. No single rule of treatment will apply in all 
cases. The anaemic condition must be counteracted on the 
principles of treatment explained under that disease ; and any 
specially abnormal state, such as diseased heart, must be 
treated accordingly. When the disease prevailed very generally 
in the Carnatic, in 1782 and 1783, some cases were most suc- 
cessfully treated by a pill containing a quarter of a grain of 
extract of elaterium, combined with extract of gentian, given 
every hour until copious watery evacuations were procured ; 
and this plan was repeated every third or fourth day, till 
with others this plan of treatment was not so successful ; the 
cases recovering best under large doses of spirits of nitre, 
antimonial wine, frictions with warm camphorated oil, aperi- 
ent medicines, wine, and a nourishing diet. Mr. Evezard's 
method of medicinal treatment consists mainly in the admin- 
istration of acetate of potash in gin, in the following for- 
mula : — 1^,. Gin, 3 ss. ; Potass. Acet., gr. v. : Aquae, J iii. ; 
misce. To be given three times a day. If vomiting persists, 
hydrocyanic acid may be useful in relieving it, to the extent 
of one drop three times a day, given in milk. In the expe- 
rience of Dr. Paterson of Bahia, a trip to Europe (if not had 
recourse to too late) is a certain cure : and medicinally, his 
patients have derived marked benefit from a combination of 
ergotine, iron and extract of belladonna, in the form of a 
pill. Sea-bathing is also acknowledged to be of great service. 

Bladder, Catarrh of— See Cystitis. 

Brain, Inflammation and Suppuration of— -See En 

cephalitis. 

Brain, TlimorS, Etc., Of. — Definition. — New growths, 
parasites, and aneurisms, implicating the cerebral substance, 
the spinal cord or their membranes, or both. 

Treatment. — Under such circumstances medicinal treat- 
ment can be only palliative; the patient may be protected as 
much as possible from hyperaemia of the brain aggravating 
the morbid state. His nutrition and mode of life must be 
regulated, and also the functions of the bowels. Apoplectic 
or local inflammatory attacks may be met by local blood- 
letting and cold compresses. Hypodermic injections of mor- 
phia are also to be used in suitable cases. If syphilis exists, 



HEIGHT'S DISEASE. 33 

or is suspected, anti-syphilitic remedies are at once to be 
adopted. 

Bl'igllt's Disease.— Definition. — A generic term, includ- 
ing several forms of acute and chronic disease of the 
kidney, associated with albumen ;n the urine, frequently with 
dropsy, and with various secondary or intercurrent affec- 
tions, resulting from deterioration of the blood. 

Treatment. — (a.) Of Acute Bright's Disease. — (i.) Relieve 
the kidneys as much as possible from the labor t of elimina- 
tion, by avoiding exposure 'to cold, by keeping the patient at 
rest in bed, in a room of moderate uniform temperature. (2.) 
The food should be scanty, consisting of gruel, arrowroot, 
milk, or weak broth. Pure water is the best drink, and alco- 
holic fluids are not to be taken on any account. (3.) Free 
action of the skin and bowels must be maintained. The hot 
air bath and antimonial remedies are the best agents to effect 
the first of these conditions, and free perspiration is to be 
encouraged by bedding the patient in blankets. Antimonial 
wine may be given in doses of from fifteen to thirty drops 
every four or five hours. The bowels are to be kept open 
by the compound jalap powder, in doses of twenty to sixty 
grains, repeated daily or on alternate days. It may be alter- 
nated with podophyllin or with extract of colocynth. Mercury 
is not to be given. (4.) Cupping over the loins relieves pain in 
the back, and the quantity of urine passed generally increases 
after eight or ten ounces of blood have been withdrawn in 
this way from an adult, or two or three ounces from a child 
three or four years old. (5.) When the tongue becomes clean 
and the general symptoms improve, mutton broth or good 
beef tea may be indulged in; and, as the digestion improves, 
solid food may be eaten in small quantities, beginning with 
fish and fowl, and afterwards mutton or beef. (6.) Flannel 
must be worn next the skin. (7.) Iron is of great service 
during convalescence, for in such cases the anaemia becomes 
extreme. Phosphate of iron, in the form of syrup, or citrate 
of iron and quinia, or the ferrum redactum, are the most 
digestible forms, and they ought to be given in small doses 
repeated after every diet. (8.) Diuretics are not to be given. 
In a case where the urine was suppressed, fomentations, con- 
sisting of infusion of the leaves of digitalis, were found by 
Christison and Vogel to increase enormously the amount of 
urine. Parkes found the amount of the albumen to diminish 
markedly from the use of the tincture of the sesquichloride 
of iron (I. a, p. 379). 
3 



34 BRIGHT S DISEASE. 

(If.) Of Chronic Bright's Disease, general principles only 
can be indicated, inasmuch as every case requires a special 
study, and a line of treatment in detail peculiar to itself. 
Whatever treatment be adopted, a long time is necessary be- 
fore any appreciable results are obtained. It is, therefore, 
necessary to persist in one line of treatment steadily from 
week to week, and even from month to month; and it is ob- 
viously of great importance to be as accurate as possible in 
diagnosis as to the probable state of the kidney, so as to de- 
fine the line of treatment from the first which may seem best 
adapted for the individual case. 

It is a question of grave importance how far vomiting or 
diarrhoea ought to be checked. If either of these occur- 
rences are suddenly stopped, the gastric and intestinal mem- 
brane acting at the time as an emunctory for the urea and 
other excreta of the urine, the patient may be suddenly cut 
off by convulsions, apoplexy, or effusion into .some of the 
serous cavities, such as the pericardium, or the pleurae, or the 
ventricles of the brain. It is necessary, therefore, in the first 
instance, to determine in all chronic cases the particular organ 
or tissue which seems in each case to be acting vicariously. 
The perspirations are often spontaneously profuse; and the 
skin is by far the safest emunctory for the vicarious elimina- 
tion of urinary constituents. Therefore it is important to 
promote the action of the skin if it be deficient, and to en- 
courage it even if it is already considerable. Diaphoretics 
are always of essential service. The best are Dover's pow- 
der, the warm bath, warm clothing, and, for convalescents 
especially, a moderately warm climate. In Sir Robert 
Christison's experience diaphoretics have always appeared 
most serviceable *when they are so given as to excite a gentle 
perspiration during a part of the night. So it is also safe to 
promote the discharge of secretions from the intestinal canal, 
with due caution that they do not become excessive, so as to 
pass into permanent diarrhoea. Urea and other constituents 
of the urine are found in such discharges in large proportions. 
When general anasarca prevails, absorption may be promoted 
by gentle pressure, which at all times must be very cautiously 
applied, and the effects closely watched, for such effusions 
afford great temporary relief to important symptoms which 
indicate the involvement of vital organs. Bandaging to pro- 
mote absorption is not justifiable so long as the anasarca is 
increasing. Patients ought to be encouraged to go about as 
long as they are able, care being taken that they are clothed 



BRIGHT S DISEASE. 



35 



with flannel and woolen garments, and otherwise well pro- 
tected from chills or draughts of cold air. 

In the subacute forms of the disease the action of the skin 
is especially to be promoted by such saline remedies as the 
acetate or citrate of ammonia, to which may be added one, 
two, or three drachms of the infusion of digitalis, and ten or 
fifteen minims of antimonial wine. In such cases, also, ten 
or fifteen minims of the tincture of the perchloride of iron, 
or from five to ten grains of the citrate of iron and ammonia 
may be given every day with one of the meals. Every second 
day a dose of the compound jalap powder may be given; and 
if hyperemia of the kidneys prevail, it may be necessary to 
take from four to six ounces of blood from the loins by cup- 
ping or by leeches. As the urine becomes more free from 
blood corpucles and albumen, the iron medicines may be 
more frequently given, and the compound jalap powder less 
frequently. A good formula for the administration of salines 
and iron in the subacute and chronic cases is that given by 
Dr. Basham and Goodfellow, as follows: 

Liquor Ammoniae Acetatis, 3 ii.; Acidi Acetici diluti, 3 i.; 
Tinct. Ferri Perchloridi, 3 iv.; Aquae, 3 iss. ; misce. Two tea 
spoonfuls for a dose. 

Small doses frequently repeated seem to do better than 
larger ones given at longer intervals. These remedies tend 
to lessen the watery state of the blood; and the action of the 
chalybeate medicines is of no avail till after purgation has 
been free, and when the hot air or warm baths have caused 
the skin to act freely. A nutritious diet is then to be given, 
combined with the chalybeate remedy. 

The quantity of urea passed by the urine should be deter- 
mined day by day, to ascertain how far the kidneys are capa- 
ble of secreting and eliminating these excrementitious pro- 
ducts. According to the results obtained the diet must be 
regulated, and such measures taken as are calculated to re- 
duce the quantity of urea, and other constituents formed 
daily, to the capacity of the diseased kidneys for the work 
they are able to do. 

The further treatment of the chronic forms of Bright's dis- 
ease is influenced by the amount of the anasarca present. 
If considerable anasarca is present, neither cupping nor 
leeches can be had recourse to, on account of the bruising 
and erysipelatous inflammation they are apt to induce. The 
chalybeate mixture already mentioned is still found of ser- 
vice, taken at least three times daily, and to it may be added 



$6 bright's disease. 

from time to time fifteen or twenty minims of the spiritus 
ostherus nitrici (Goodfellow). 'The citrate of iron and am- 
monia, in from five to ten grain doses, with the sulphuric or 
chloric ether, are also good and useful remedies; and if the 
iron medicines are found too stimulating, sulphate of zinc, 
or tannic and gallic acids, may be used instead. The sul- 
phate of zinc is to be given, in doses of one to three grains 
three times a day, in the form of a pill, made with extract of 
hop, and with or without a grain of the extract of nux 
vomica; or the same dose of sulphate of zinc may be given 
in a draught combined with sulphuric or chloric ether (Good- 
fellow). These latter medicines relieve considerably the flat- 
ulence and sensation of coldness in the stomach and bowels, 
so much complained of in such cases. 

If the urine is " smoky," or if blood is seen on microscopic 
examination, the gallic acid, in five or ten grain doses, may be 
given, with a few drops of diluted sulphuric acid and a few 
drops of the tincture of hops, or other aromatic vegetable tinc- 
ture, in an infusion of the same. The objection to these rem- 
edies is the constipation they arc apt to induce. The bowels 
should always be kept relaxed, two or three loose evacuations 
being secured daily. The medicine most generally useful is 
the compound jalap powder of the London Pharmacopoeia, 
which should be taken in the morning fasting, in half drachm 
or drachm doses, in a wine-glass of water. It does not induce 
prostration, but by repetition it is apt to lose its effect, when 
elaterium may be necessary in small but repeated doses; two 
grains of elaterium being dissolved in sulphuric ether, and the 
eighth of a grain given every six hours till the desired effect is 
produced. Very abundant watery purgation is thus obtained, 
and a sensible impression is made upon the distended dropsi- 
cal parts (Basham). If elaterium may not be deemed advisa- 
ble, a saline draught of the following composition may prove 
efficient: 

PjL Magnes. Sulph. vel Sodas Sulph., 3 i. to 3 ij.; Athens 
Sulph., m x.; Acid. Sulph. dil., m x.; Ferri Sulph., gr. i. to ii. ; 
Aq. Menthae Vir., § iii. to 3 iv. 

This draught is to be taken the first thing in the morning 
once or twice a week. It ought to produce two or three loose 
and watery evacuations (Goodfellow). 

Diuretics are a most certain and speedy remedy when the 
dropsical effusions are considerable; and they are sometimes 
advisable when the urine is scanty, although they are seldom 
necessary in the treatment of the fundamental disease. Sir 



BRIGHT S DISEASE. 37 

Robert Christison is convinced that the fears entertained by 
some of injury being produced by the stimulus of diuretics on 
the kidneys are visionary. In his experience, over more than 
forty years, the best diuretics are digitalis, squill, and bitar- 
trate of potash, taken simultaneously; and, if these fail, Hol- 
lands spirits sometimes speedily establishes the diuresis. 

When dyspeptic spmptoms predominate, and there is con- 
siderable flatulence, the following pill is recommended byDr. 
Goodfellow to be taken twice or thrice daily: 

$. Ferri Sulphatis, gr. i.; Ext. Nucis Vomicae, gr. y? to 
i.; Mas. Pil. Galb. Co., gr. ii. to hi.; misce, flat pilula. 

And if there be co-existent bronchitis, a draught of the 
acetate of ammonia, with ten, fifteen or twenty drops of the 
spiritus setheris nitrici, and half a drachm of the oxymel of 
squills, is to be taken intermediately with the pills. If much 
nausea prevail three minims of dilute hydrocyanic acid may 
be added to the draught, with occasional application of mus- 
tard to the stomach. 

Want of sleep is often complained of, but opiates are in- 
advisable, because they are apt* to check the secretions and 
to occasion constipation. Henbane may be given in place 
of opium. 

The patient should select a residence where the soil is san- 
dy or chalky, where the air is mild and dry, so that as much 
open-air exercise may be taken as possible. 

Diet should be light, but nutritious; no pastry should be 
eaten; and stimulant liquors should be used with caution, al- 
though, when exhaustion is great, their use may be unavoidae- 
able. The principal meal should be in the middle of the 
day, but not later than three o'clock; and the last meal should 
be taken two or three hours before bedtime, retiring early to 
bed, and rising early. Light but warm woolen clothing is to 
be always worn — in summer as well as in winter. 

* The complications of Bright' s disease are extremely diffi- 
cult to manage. The diarrhoea must not be suddenly 
checked. Thirty to sixty minims in water of the spiritus 
ammoniae aromaticus, with half a drachm of the tincture of 
kino or of catechu, after every loose stool, will in general be 
all that is necessary. If there be much griping, the applica- 
tion of a linseed poultice over the abdomen, with two 
drachms or half an ounce of tincture of opium sprinkled 
over it, will give relief (Goodfellow). When it is found nec- 
essary to use measures for checking the diarrhoea, means 
should be taken that the skin acts freely, or that the urine 



38 bright's disease. 

flows increased in quantity. Lead and opium pill (pilula 
plumbi cum opio), in doses of five or ten grains twice or even 
thrice a day, is the best remedy for checking diarrhoea. These 
remedies may be aided by a suppository of the hydrochlorate 
of morphia occasionally, each suppository containing a quar- 
ter of a grain of the hydochlorate of morphia (morphias hy- 
drochlor. suppositorise). Vomiting may be controlled to some 
extent by bismuth, but more frequently by morphia, hydrocy- 
anic acid, creasote, rectified pyroxylic spirit, chloroform, or 
chlorodyne, or little fragments of ice; and if these fail, a blis- 
ter over the epigastrium has sometimes succeeded (Sir Robert 
Christison). 

Intercurrent inflammatory attacks and effusions into cavi- 
ties are still more difficult complications to manage. The ap- 
plication of a few leeches, or the abstraction of a few ounces 
of blood by cupping, may be borne well in cases with head 
complications; but the greatest care and caution are required 
in the employment of similar remedies in the complication of 
pericarditis, on account of, the great danger of death by 
syncope. 

Bronchial complication are serious, and more or less con- 
stantly present. They are frequently the immediate cause of 
death in chronic Bright's disease. The least stimulating ex- 
pectorants may be administered under such circumstances. 
The following formula is recommended by Dr. Goodfellow: 

1^. Liquor Ammonias iVcetatis, 3 ii. to 3 iii. ; Spiritus 
CEtheris Nitrici, raxx. to 3 ss.; Oxymellis Scillas (Lond.), 
3 ss.; Aquae Camphoras et Aquas aa 3 v.; misce, fiat haustus. 
To be taken every four, six, or eight hours. 

If the expectoration be viscid and difficult to discharge, a 
few drops of antimonial wine may be added to the draught; 
or if there be much spasm of the bronchial tubes, as indicated 
by the asthmatic breathing, a few drops of sulphuric or 
chloric ether may be given. If, on the other hand, the ex- 
pectoration be purulent and difficult, a few grains of carbon- 
ate of ammonia may be given with the oxymel of squills. 
Every precaution ought to be taken to prevent a fresh attack 
of bronchitis. So long as the patient is able to bear it, the 
habit of cold sponging and dry rubbing of the surface of the 
body every morning with a flesh brush or coarse towel is the 
best preventive, and being clad in warm woolen clothes. 
Flannel next to the skin must be invariably insisted on. 

Mercurial preparations are contraindicated in Bright's dis- 
ease — so great is the tendency to salivation and the otherwise 



BRONCHIAL CATARRH. 39 

injurious effects they produce. Podophyllin (the active prin- 
ciple of the May apple) may be used instead. Its dose is from 
i to i grain; and it ought not to be given in doses larger than 
one grain. It is best given in a fluid form (see p. 902, ante), 
or a pill with soap and hyoscyamus. As an occasional mild 
aperient pill, the following is found to answer well: 

5- Mas. Pil. Rhei. Comp., gr. ii. to in.; Vel. Ext. Aloes, 
Aquosi, gr. i.; Ext. Nucis Vomicae, gr. i.; Mas Pil. Galb. Co., 
gr. ii. ; misce. fiat pilula (Goodfellow). 

Bronchial Catarrh. — Definition. — Infiltration and oede- 
ma of the mucous membrane of the bronchial tubes, so that 
tumefaction diminishes their calibre, attended first with dry- 
ness of surface, followed by a watery secretion, which subse- 
quently becomes turbid and yellow. The disease is some- 
times attended with chilliness and the discomfort of what is 
called a " common cold." 

Treatment. — When the symptoms of a " common cold " 
first express themselves, when the attack is sudden, attended 
with marked depression, aching pains in the head, back, and 
limbs, and febrile disturbance (and even when the sensations 
have extended to the chest, as indicated by the hoarseness 
and tendency to cough), the disease may be at once subdued 
in a healthy person by a full stimulant (but not narcotic) 
dose of opium or morphia. " One-third or one-fourth of a 
grain of muriate of morphia, or one grain of opium, ought to 
be taken at bedtime. Its influence will begin to be felt in 
from twenty minutes to half an hour, by the gradual disap- 
pearance of the sense of intense weakness, the relief of the 
pains, and that peculiar feeling of thorough and evenly dis- 
tributed warmth of the whole body which is so different from 
fever on the one hand, or chilliness on the other" (Anstie, 
op. cit., p. 120.) An alcoholic diaphoretic drink; or five 
grains of carbonate of ammonia, or ten to twenty grains of 
muriate of ammonia; or, if the appetite is unimpaired, a full 
supper, followed by a hot alcoholic stimulant, may have a 
similar effect to opium. Natural sleep ought to supervene, 
and the morning ought to find the patient well. The follow- 
ing formula has been recommended as an anticatarrhal olfac- 
tory, originally prescribed by Dr. Hagner; 3 Carbolic acid, 
5 parts; rectified spirit of wine, 15 parts; strong solution of 
ammonia, 5 parts; distilled water, 10 parts. The mixture is 
kept in a stoppered dark glass bottle. When a catarrh is 
commencing, a few drops are placed on three or four layers 
of blotting or filtering paper; the patient holding this in his 



40 BRONCHIAL CATARRH. 

hand, and closing his eyes, inhales deeply from it as long as 
any smell is perceptible. The effect is to cut short the acute 
stage of the cold, to prevent the occurrence of subsequent 
coryza and bronchial and laryngeal catarrh; while all trouble- 
some symptoms are rendered much milder. The remedy 
should be applied every two hours (Dr. E. Brand, Wiener 
Med. Wochenschrift, June 15, 1872). Snuffs composed of 
morphia and subnitrate of bismuth are also found useful when 
coryza is present — e. g., muriate of morphia, gr. i.; powdered 
gum arabic, 3 i. ; subnitrate of bismuth, 3 hi. ; and oxide of 
zinc may be added in the proportion of 40 grains. This com- 
pound powder is to be repeatedly and thoroughly snuffed 
into the nostrils. 

If such remedies are delayed too long, the object next to 
aim at is to induce a copious perspiration and a continued 
action of the skin and kidneys, by small doses, frequently re- 
peated, of antimonial and ipecacuanha wines, or nitrate of 
potash, or acetate of potash, as well as bicarbonate of potash 
and aqua potassoe, combined at a later period with tinctures 
of squills and hyoscyamus. In the early stage of the disease 
the bronchial membrane has its normal moist condition al- 
tered to a dry state; and the object of treatment is to bring 
about a return of the naturally moist condition. This is 
best effected by the inhalation of the vapor cf hot water, the 
use of tartar emetic in doses of one-twelfth to one-sixth of a 
grain, the use of ipecacuanha in one-quarter or half-grain 
doses. From the frequent inhalation of steam great benefit 
is derived. Opium has often been regarded as hurtful in the 
first stage, because it has been taught that it interferes with 
the free secretion of mucus; so as to render expectoration 
difficult. But the onset of the catarrh — i. c., free expectora- 
tion, is in consequence of the abatement of the inflammation, 
which opium tends to subdue, and in this respect it acts as 
an expectorant. Thus it is often of great service in the first 
stage of a common cold, as it is in most acute inflammations 
(Flint.) The inhalation of iodine vapor every three or four 
minutes for an hour is of service, each inhalation lasting one 
minute, by merely holding a bottle of tincture of iodine in 
the warm hand under the nose (Tanner.) Total abstinence 
from liquids for forty-eight hours, originally recommended 
by Dr. Richard Lower, one hundred and forty years ago, is 
a practice recently revived by Dr. C. J. B. Williams. Muri- 
ate of ammonia, 3 ss. in solution, is a remedy also much in 
use, combined with liquorice or simple syrup, with one grain 



BRONCHIAL CATARRH. 41 

of tartar emetic and one or two drachms of antimonial wine, 
dissolved in six or eight ounces of water. Of this a table- 
spoonful for a dose, frequently repeated, may induce relief, 
when the discharge from the nose and trachea is viscid. 
Copious warm drinks and abundant warm bed-clothing, to 
induce diaphoresis, are efficient remedies to be used early. 

The object aimed at in the treatment of a " common cold" 
is to establish a free catarrh — to soften the expectoration and 
make coughing " loose " and easy. Niemeyer lays down 
some practical rules, based on symptomatic indications, to 
accomplish these ends : — (i.) In chronic colds or catarrhs, 
where cough is incessant and distressing, and out of propor- 
tion to the expectoration, narcotics are indicated — such as 
ten grains of Dover's powder at bed-time, or the camphorated 
tincture of opium (paregoric elixir). External counter-irri- 
tants are also of service, in the form of mustard poultice, 
" mustard leaves," or blistering substances, short of vesica- 
tion, such as stimulating liniments. Chlorate of potass is 
also a useful remedy. (2.) Dyspnoea, with extensive sibil- 
lant rhonchus and irritability of the mucous membrane, are 
also relieved by narcotics, combined with ipecacuanha, or 
with tartar emetic. But narcotics are contraindicated if, ow- 
ing to the feebleness of the patient, the efforts of expector- 
ation are inadequate to prevent accumulation in the bronchial 
tubes. Alkaline carbonates possess the property of thinning 
and rendering easier of expectoration the viscid bronchial se- 
cretion, and are on that account to be recommended, especial- 
ly where the condition of the urine suggests such remedies. 
Opium in its many forms is the most useful remedy, so long 
as the first stage of inflammation exists, if care be taken to 
watch that nothing contraindicates its administration. Pre- 
parations of conium, hyoscyamus, or hydrocyanic acid, must 
be used in cases where opium is contraindicated. 

(3.) When secretion is profuse, with relaxation of the mu- 
cous membrane of the bronchi, when large, soft, moist rales 
are heard, stimulant expectorants are indicated, — senega, 
squills, carbonate of ammonia, benzoin, gum ammoniac, and 
oil of cubebs. Remedies in the form of gas are also of ser- 
vice, such as the fumes of tar, by boiling it alone or mixed 
with water; also vapor of turpentine, half a drachm being put 
into a bottle of hot water, the patient inhaling for a quarter 
of an hour, four times a day. In all cases absolute rest, veg- 
etable diet, demulcent drinks, and small doses of antimonials 
will greatly tend to bring about relief. A pint of any demul- 



\2 BRONCHITIS. 

cent fluid (such as linseed tea), with two drachms of anti- 
monial wine, taken in small quantities, so as to be consumed 
in twenty-four hours, will be found a good standard prescrip- 
tion. Gum arabic, in the proportion of one ounce to the pint 
of water, or decoction of marsh mallow, or of dried fruits, is 
a good substitute for the linseed, and may be flavored with 
anything agreeable to the taste of the patient, such as orange 
or lemon syrup. If much fever exists, a very hot foot-bath, 
just before going to bed, has a soothing effect. The air of 
the bed-room must be kept at about 6o° Fahr., not below, 
and the patient must remain as quiet as possible. 

Generally, in prescribing cough mixtures, which ought if 
possible to be avoided (seeing that they so impair the func- 
tions of the stomach), the following conditions ought to be 
adhered to in devising the mixture: — (i.) That the prescrip- 
tion should- be in the form of fluid remedies, — solution, or in- 
fusion of wines or syrups of the drugs. (2) That the dose 
should not exceed one teaspoonful. (3) That the propor- 
tions contained in the mixture should be so arranged that a 
dose may be given every two, three, four, or six hours, ac- 
cording to the urgency and acuteness of the symptoms. Such 
a mixture may contain in each dose, for an adult, from ten to 
thirty minims of antimonial wine, or of ipecacuanha wine, or 
of tincture of sanguinario, or of syrup of squills, or of vinegar 
of squills, with two minims to four minims of hydrocyanic 
acid, or thirty to sixty minims of tincture of hyoscyamus or 
of conium; or from two to four minims of tincture of opium; 
or from thirty to sixty minims of camphorated tincture of 
opium. 

Bronchitis. — Definition. — Inflammation of the air-pas- 
sages leading to the pulmonary vesicles, characterized by 
hoarseness, moderate cough, heat, and soreness of the chest 
anteriorly — symptoms which are more and more intense ac- 
cording to the severity of the disease, and especially the ex- 
tensive implication of the smaller tubes. The natural mu- 
cous secretion is at first arrested, but subsequently it becomes 
increased in amount and altered in quality, tending to assume 
the corpuscular character. 

Treatment. — {a.) In acute bronchitis. — General bleeding 
uniformly weakens the patient. In severe cases of acute 
bronchitis some blood may be taken from the chest, with 
great caution not to take too much, either by cupping be- 
tween the shoulders or by leeches, and in general from ten to 
twelve ounces are sufficient. It is only in extensive conges- 



BRONCHITIS. 



43 



tion of venous circulation threatening asphyxia, that genera] 
blood-letting is imperative. Next to blood-letting, tartarized 
antimony, administered in solution in doses of a sixth or a 
quarter of a grain, every three or four hours, conduces to free 
secretion, and generally to mitigate the symptoms of the dis- 
ease. Digitalis is a useful adjunct to the antimonial treat- 
ment. When the expectoration becomes thicker and less 
copious, the antimony may be decreased, and squills, or ipe- 
cacuanha, with paregoric, given. After this a blister should 
be applied to the chest; and on its removal a large linseed 
poultice should be placed near the blistered part, and con- 
tinued for many hours. The bowels should be freely evacu- 
ated by a purgative dose of calomel, combined with com- 
pound jalap powder, and they should subsequently be kept 
in regular and gentle action by some neutral salt, such as sul- 
phate of magnesia in the liquor ammoniae acetatis, combined 
at the same time with some nitrate of potass. The neutral 
citrates, tartrates, or acetates of the alkalies are useful elim- 
inating remedies. 

After the severe symptoms at the outset have been sub- 
dued, expectoration should be promoted by squills, ipecac- 
uanha, and tartar emetic, combined with hyoscyamus or 
conium. Opium in narcotic doses (/. e. } above a grain) is in- 
admissible, because its tendency is to paralyze the action of 
the mucous passages in eliminating secretion. After secretion 
has begun to diminish, in acute cases opium may be pre- 
scribed with benefit in stimulant doses, in the form of solution 
of the salts of morphia, added at bedtime to the doses of the 
cough mixtures so usually administered. (See under Bron- 
chial Catarrh.) If the disease shows a disposition to pass into 
the chronic stage, quinine, with squills and conium, may be 
administered, or a draught containing full doses of cinchona, 
with five grains of carbonate of ammonia, or ten to twenty 
grains of the muriate of ammonia, and thirty or forty minims 
of the compound tincture of benzoin (Friar's balsam), or of 
the balsam of Peru, will generally facilitate expectoration 
and relieve the dyspnoea. If a "hearty cough" is not at- 
tended by easy and free expectoration, but the chest remains 
loaded, stimulant expectorants may be given in aid of other 
remedies, such as the decoction of senega, or the mistura 
ammoniaci (Fuller). The patient throughout the treatment 
should remain in a room where the air is kept moist by the 
evaporation of boiling water from large flat dishes near the 
bed, and the temperature of the air should be maintained at 



44 BRONCHITIS. 

63 to 68° Fahr. Alike in acute and in chronic cases, io- 
dide of potassium is of great service. It lias a marked effect 
in reducing the frequency of the respirations.' It is best 
prescribed with carbonate of ammonia, and if cough is very 
troublesome, tincture of belladonna and ipecacuanha wine 
may be added. 

(l>.) In chronic bronchitis, especially in patients who have 
made considerable progress in the journey of life, a lower 
tone of the system prevails. A greater laxity of aerian mem- 
brane — particularly with excessive secretion, often muco-pur- 
ulent — characterizes them ; and after blistering and poultic- 
ing the chest repeatedly with linseed and mustard poultices, 
the treatment in general should be more tonic. The cam- 
phorated mixture or paregoric and stimulant expectoranv 
remedies are indicated for occasional, but not for constant 
use. Stimulating embrocations may be rubbed not only over 
the chest, both before and behind, but along the sides of the 
neck. 

A liniment composed of the following ingredients was ex- 
tensively employed by the late Drs. Graves and Stokes in ths 
Meath Hospital, Dublin : — 

I*. Spt. Terbinthin?e, 3 iii.; Acid. Acet. 3 iv.; Vitelli Ovi, 
i.; Aq. Rosoe, 3 iiss. ; 01. Limon., 3 i.; misce. 

It is to be applied as a rubefacient, morning and evening, 
when it generally reddens the skin and produces small pim- 
ples. In several cases the secretion of the kidneys is increas- 
ed during its use (Maclachlan). Of tonic remedies most re- 
liance may be placed on the influence of mix vomica, iron, 
and quinine, in the form of a syrup composed of the phos- 
phates of strychnia, of iron, and of quinia ; so that, in doses 
of a teaspoonful three times a day, each dose shall contain 
the thirty-second part of a grain of phosphate of strychnia, 
and one grain respectively of the phosphates of iron and 
quinia. (Formula for the preparation of this compound, see 
"Anaemia.") The inhalation of slightly irritant vapors has 
a beneficial effect, as of vinegar, turpentine, chlorine and io- 
dine. Of the fetid gums, ammoniac in particular is a useful 
remedy. An emulsion of gum ammoniac in diluted nitric 
acid, is a combination from which beneficial results are ob- 
tained. The following is a formula for its prescription — 
namely, an hundred and twenty grains of the gum ammoniac 
dissolved in two fluid drachms of diluted nitric acid and 
twelve ounces of water, compose a mixture of which an ounce 
may be given in gruel cr barley-water three times a day 



BRONCHITIS. 



45 



(Easton, Glasgow Med. Jour , Oct. i, 1S63). It may also 
be advantageous to administer astringent remedies, and one 
of the most useful is tannic acid, in doses of one to three 
grains two or three times a day ; or the oil of cubebs to the 
extent of ten drops three or four times a day on a piece of 
sugar (see under treatment of "Phthisis"). 

Acute bronchitis is apt to be latent in old people, and to be 
complicated with gastric or gastro-enteric inflammation 
(Maclachlan). The stimulants of food (by enema in the 
form of soup, without salt, if unable to be taken by the 
mouth) aud of alcohol are the main remedies necessary from 
the very beginning. Abstinence cannot be enforced with 
safety. Leeches must be applied to the pained gastric re- 
gion. When the disease is associated with a tendency to 
gout, colchicum must be given. " It allays the cough, pro- 
motes the flow of urine, keeps up a regular alvine discharge, 
and can be given much more generally than squills, because 
it does not produce that feverishness which results from the 
use of the latter remedy, and can therefore be employed 
where there is considerable fever " (Forbes). It requires to 
be administered with great caution in the aged and infirm 
(Maclachlan). In the protracted bronchitic affections of the 
aged, diuretics are of great service. The following formulae 
are recommended by Drs. Maclachlan and Stokes. 

3. Decocti Senegse, f 3 vij. ; Potassse Nitratis, gr. hi.; 
Tinct. Camph. Comp. vel Tinct. Conii, m xx.; Spiriti ./Ethc- 
ris Nitr., f 3 ss. , Oxymellis Scillce, f 3 ss. Fiat haustus ter 
die summendus (Maclachlan). 

r). Liq. Amnion. Acet., 3 ill- ; Potasses Acetatis, gr. xx.; 
Aceti Scillse, f 3 ss.; Spirit. JEth. Nitr., f 3 ss.; Tinct. Camph. 
Co., m xx.; Mist. Camph., 3vi.; Syrupi Aurant., 3 i- (Mac- 
lachlan). Fiat haustus ter die summendus. 

t^. Decocti Senegas, 5 v.; Tinct. Camph. Co. Tinct. Scil- 
lae, a a 3 ii. ; Syrupi Tolut, 3 iv. Sumat 3 ss. vel. 3 i. ter 
die (Stokes, Maclachlan). 

When gastric irritation prevails, the administration of bal- 
sams, gum resins, and terebin thine remedies must be sus- 
pended. 

(<r.) In capillary bronchitis the treatment must be strictly 
conservative ; spoliative remedies lessen, if they do not de- 
stroy, the chances of recovery. The tendency to death is by 
apncea, from the imperfect oxygenation of the blood — the 
area of available respiratory surface being greatly diminish- 
ed, both from the morbid state of the minute bronchi and 



46 BRONCHOCELE— CANCER. 

the accumulation of diseased products in them. The pa- 
tient must be properly and adequately nourished. Stimu- 
lants are often required, and tonics should be early adminis- 
tered. The chest must be covered with hot poultices, and 
an oil-silk jacket worn over them. Dry-cupping has seemed 
to give relief to urgent symptoms. The muriate of ammonia 
— two grains every two hours — either alone or in combina- 
tion with the chlorate of potash : and the carbonate of am- 
monia has long had a certain reputation in capillary bron- 
chitis, especially in the later stages. 

(d.) In bronchiectasis opiates are required to relieve 
cough ; balsamic remedies (tolu, tar, benzoin, turpentine, 
copaiba, cubebs) and astringents, like catechu or rhatany, 
with the use of counter-irritants and the inhalation of vari- 
ously medicated vapors, are all useful aids in ameliorating 
the condition of the patient. Muriate of ammonia and the 
alkalies are also to be recommended. Inhalation of disin- 
fectants, capable of being so used, such as creosote, carbolic 
acid, sulphur vapor, turpentine, and the like, are of special 
service (see under treatment of " Phthisis "). 

(e.) Plastic Bronchitis. — In the acute form, muriate of 
ammonia and the alkalies and iodide of potassium may be 
given, with an occasional emetic, and inhalation of the vapor 
of hot water. The patient should be carefully protected 
against damp and sudden changes of weather. 

BroncllOCele — See Goitre. 

Br OllcliOCele, Exophth aim ic — See Goitre, Exohpthalmic. 

Cancer. — Definition. — A growth consisting of a delicate 
fibroid stroma, containing within its meshes aggregated but 
not coherent cell-elements — cells, nuclei, or granules — gener- 
ally UN-uniform, though often similar to natural cell-ele- 
ments. It tends not only to spread continuously irrespective 
of the tissue invaded, and to multiply its elements indefinite- 
ly, and so to infiltrate into the surrounding structures, especi- 
ally in the course of the lymphatics and nerve sheaths of the 
part affected ; but it also tends to infect or reproduce itself 
in more remote and internal parts of the body ; and finally, 
it tends to progressive softening and ulceration, with ulti- 
mate poisoning and exhaustion of the system. It is in this 
dynamical specific force of growth, spread, infectiveness, and 
multiplication, that the " malignancy" of "cancer" is ex- 
pressed ; and by virtue of which it is a disease sui generis. 

. Treatment. — No remedy has yet been found which can in 



CANCER. 



47 



any degree be considered curative of the constitutional state 
associated with cancer, and the efforts of the practitioner are 
consequently limited to relieving symptoms, and to the adop- 
tion of such palliative measures as may prolong life. It has 
generally been believed that to remove a cancerous growth 
where it is practicable must, on theoretical grounds merely, 
be attended with as much benefit to the constitutional dis- 
ease as would attend the removal of a leg for acute rheuma- 
tism chiefly expressed in the knee-joint. The statistics of 
cancer show, so far as they go, and as Dr. Walshe long ago 
showed, that " excision of a cancerous tumor seems to awaken 
a dormant force. Cancers spring up in all directions, and 
enlarge with a power of vegetation almost incredible." Never- 
theless, there are good reasons for removing cancers in some 
cases, especially mammary cases and others accessible to the 
knife. The greatest measure of good may be done, as Sir 
James Paget has clearly shown, " by making a careful selec- 
tion, of cases fit for operation, and rejecting all the rest as 
unsuited for operation" {Med. Times and Gazette, September 
27, 1872, p. 319). With regard to excision of the breast for 
cancer, the main objection in the first instance is, that even of 
cases selected with some care, 10 per cent. (Paget) to 16 per 
cent. (Lebert) die of pyaemia, or erysipelas, or tetanus, or 
secondary haemorrhage, or some calamity subsequent to the 
operation. On the whole, however, taking the results of some 
hundreds of cases, it is certain that the average duration of life 
of those operated on is not less than those in whom the disease 
runs its course. In well-selected cases it will be found always 
greater. A recent tabulation of hospital and private cases by 
Sir James Paget showed that 85 cases operated on lived an 
average of 55.6 months ; and 62 cases not operated on lived 
an average of three months. It has also been said that the 
recurrent disease is more painful than the primary one ; but in 
very many cases Sir James Paget has found that the recurrent 
disease was much less severe than the continued disease. 
Considering, therefore, the danger of the operation, and the 
fact that in every case a recurrence of the disease maybe ex- 
pected, it is reasonable to submit a patient to the risk of dying 
from the primary operation for the sake of that interval of 
health between the operation and the recurrence of the disease, 
for the good probability of adding a year to life, and for. the 
chance of having a less severe disease ? The average length 
of the interval before recurrence is little more than thirteen 
months : more than half return within twelve months : and 



48 CANCER. 

two-fifths return within six months. The extremes between 
which the average is drawn are very wide. In some cases the 
return may be within three months ; in others not for ten, 
twelve, or more years. It is of great importance to determine 
in what cases the risk of life is greater ; and in what cases the 
probability of a speedy return of the disease is greater than 
the average. The old after sixty ; the very large-breasted 
in cases of mammary cancer ; the fat and plethoric ; the 
cachectic ; the over-fed on animal food ; the drunkards ; the 
gouty • the habitually bronchitic ; the albuminurious ; the 
very dejected — not timid merely ; in short, those with any or- 
ganic disease of the internal organs — all such cases are 
" doubly hazardous" to interfere with by operation (Paget.) 
The probability of rapid recurrence is great in acute can- 
cers — i. e. all those that are rapid in their progress — and in 
those which are observed to increase very quickly before the 
operation. Great pain, however, is often saved by performing 
the operation even under such circumstances. In illustration, 
Sir James Paget records the case of a lady " whose breast he 
removed when she was five months advanced in pregnancy. 
She recovered well from the operation, and the benefit pro- 
cured by its performance was very great. She went to her full 
term, bore her child, and was able to suckle it for a year be • 
fore she died, with her most anxious wish fulfilled in compara- 
tive comfort." Another condition unfavorable to operation 
is a brawny skin, with firm oedema and wide-open hair follicles 
or wide adhesion of skin, or in which the skin is cancerous, 
or where there are scattered tubercles of cancer in the glands 
and skin ; or where there is considerable affection of the 
lymph-glands in the vicinity, and especially numerous dis- 
eased glands. A moderate amount of lymphatic disease is 
not a serious obstacle to an operation (Sir James Paget). 
In very chronic cases the operation is needless — where the 
breast is small, shrivelled, knotty, and sunk down on the pec- 
toral muscle. By thus selecting with care, on the one hand, 
cases fit for operation, and refusing to interfere in those cases 
in which the operation would be attended with more than a 
proper share of danger, Sir James Paget believes that the life 
of a large number of those who suffer from cancer may be 
considerably prolonged. In whatever part the disease may 
be situated, one great rule is to endeavor to restore the 
healthy functions of that part, and to alleviate by opiates, 
chloroform, or chlorodyne internally, the distressing pains the 
patient endures. These remedies are for a time uccessful, 



CANCRUM ORIS. 49 

but make no impression on the disease, which silently pro- 
ceeds, and the patient finally limits himself altogether to 
opiates. The quantity of opium or other narcotic known to 
have been taken in such cases is something enormous — five, 
ten, fifteen, or twenty grains of opium at a dose, or a propor- 
tionate quantity of hyoscyamos or of conium, three, four, or 
more times in the twenty-four hours. But although these 
large 'doses have occasionally been given, yet it may be ques- 
tioned whether they are not more hurtful than beneficial ; 
for usually they produce headache, delirium, loss of appetite, 
and narcotism, so that the patient is only the more rapidly 
exhausted. In general, therefore, the patient does better 
under moderate doses of opiates, as one or two grains, or its 
equivalent of morphine or other narcotic, every four, six, or 
eight hours, than when more excessive doses are given — a 
larger dose producing headache and much cerebral distur- 
bance, without in any sensible degree mitigating the suffer- 
ings. When the disease is seated in the colon or intestine, 
the tumor is in general difficult to make out. One loop of in- 
testine may open into another ; and death by haemorrhage 
may terminate the case. The symptoms vary greatly accord- 
ing to the position of the cancer and the part of the intestinal 
canal affected. Great sickness and vomiting generally attend 
cancer in the duodenum. When the stomach is so irritable 
that it rejects everything, it is our duty to support the pa- 
tient by nutritive injections, as of strong broth, egg-flip, sago, 
or other fluid substances. It has been attempted to impart 
strength to the patient by means of milk baths, or baths of 
strong broths ; but the skin has not generally sufficient power 
of absorption, and it has been found that the heat of the bath 
has exhausted the patient in a far greater ratio than its nutri- 
ment supported him. As a general principle, diet has little 
or no influence over the course of the disease when once es- 
tablished, except it may be that total abstinence from nitro- 
genous food may starve out the growth, and most likely also the 
patient ; so that whatever agrees with the patient's digestion 
may be safely indulged in. Preventive treatment must be 
directed to the infant life of those who are hereditarily pre- 
disposed. 

CancruiIL Oris. — Definition. — The more severe form of 
inflammation of the mouth. 

Treatment. — The disease is analogous to hospital gangrene, 
and an early recognition of its nature will suggest an efficient 



50 CATALEPSY CEREBROSPINAL MENINGITIS. 

application of strong nitric acid to the slough. The mouth 
must be frequently syringed with a solution of carbolic acid, 
in the proportion of half a drachm dissolved in a gallon of 
boiling water, and allowed to become warm or tepid. 

Tonics and antiseptics must be freely given. Beef-tea, 
wine, brandy, quinine, and chlorate of potash are also in- 
dicated. 

Carcinoma — See Cancer. 

Catalepsy. — -Definition. — A sudden suppression of con- 
sciousness; but instead of falling down convulsed, as 
in hysteria, the patients maintain the position in which 
they were when the attack commenced. The limbs 
and trunk persist in a state of balanced muscular con- 
tractions; the same expression of countenance is pre- 
served which may chance to be at the moment of seizure. If 
sitting, the patient continues to sit; if standing, he continues 
to stand; if occupied in any mechanical employment, he 
continues fixed in one attitude; and if he is under the in- 
fluence of any passion, the countenance retains its expres- 
sion. 

Treatment. — No constant line of treatment can be stated. 
The individual case must be judged of upon its own merits, 
and prescribed for according to the principles which have 
guided the dictates of treatment in the allied nervous affec- 
tions. 

Catarrh, Epidemic — See Influenza. 

Cephalalgia — See Headache. 

Cerebro- Spinal Fever — See Cerebrospinal Meningitis. 

Cerebro- Spinal Meningitis. — Definition. — A fever be- 
lieved to be of an acute specific character, of sudden inva- 
sion, attended by painful contraction of the muscles of the 
neck and retraction of the head. In certain epidemics it 
has been accompanied by a profuse purpuric eruption; and, 
occasionally, by secondary effusions into certain joints. 
Lesions of the brain, the spinal cord, and their membranes, 
are found on dissection. The course of epidemic cerebro- 
spinal fever is rapid, attended with great prostration of the 
powers of life, severe headache, and pain along the spine. 
The variations of temperature are so great that no typical 
range can be given; and the result is generally fatal.. 

Treatment. — At the outset, stimulating embrocations to 
the spine and extremities with moist or dry heat to the 



CHELOID— CHLOROSIS. 5 J 

limbs, and wrapping in blankets, give some relief. Opium 
in large doses is the only drug which has appeared to be of 
any service in subduing the virulence of the symptoms. 
Quinine, in cases where malaria aggravates the disorder, is 
also well spoken of. Ether and chloroform inhalation have 
been of use as sedatives; and tincture of cantharides has been 
of service in cases marked by extreme depression. Counter- 
irritation, by the actual cautery applied along the spine, or 
by blisters, has been followed by alleviation of the pain and 
other symptoms. The energetic use of cold, as of ice com- 
presses to the head, of leeches behind the ears, and of 
calomel, as in sporadic meningitis, are measures to be recom- 
mended. 

Cheloid. — Definition. — A tuberculated growth or swell- 
ing of the true skin occurring spontaneously or upon a 
cicatrix. 

Treatment is not yet defined; but the history of the dis- 
ease points to cold applications and tonic remedies as the 
basis of a rational treatment. 

Chicken-Pox. — Definition. — A disease the result of a 
specific cantagium capable of inoculation, and having a 
period of incubation of eleven days (Murchison and Squire) ; 
it consists of a specific eruption, in a series of new crops, 
usually appearing for several days in succession ; so that 
dried and fresh vesicles are often alongside of each other, on 
the breast, back, face, and extremities, preceded by fever. 
The disease may be protracted for a fortnight or longer, and 
may be epidemic. It affects the system only once. 

Treatment consists simply in abstinence from animal food; 
having recourse to a milk diet ; and careful attention to the 
bowels by saline luxations if necessary. The patient is to be 
kept at perfect rest and cool, by making him repose on a 
mattress rather than on a feather bed, with light coverings. 
It is necessary to be on the lookout against catarrh. 

Chlorosis. — Definition. — A deficiency of the blood-cells 
with redundancy of the serous part of the blood, occurring 
in young girls at the age of puberty ; in the young of both 
sexes before the complete development of the distinctive 
characters of the sexes towards puberty ; and sometimes dur- 
ing pregnancy. 

Treatment is chiefly conducted by change of air and diet, 
by moral and physical hygiene, and by medicines. All the 
functions of the body must be carefully observed and regu- 



$2 CHLOROSIS. 

lated. The residence of the patient must be a reputed 
healthy spot, in the pure air of the country, rather than the 
town. Dry frictions of the back and limbs are also recom- 
mended, with bathing in the sea, where it can be borne. 
The food must be regulated so as not to be too stimulating 
nor disgustingly bland ; frequent change is demanded, with 
a due attention to the proper apportioning of nutritive and 
respiratory elements. The diet should be generous, and 
carefully apportioned to the powers of digestion. Any 
symptoms of dyspeptic oppression, impaired digestion, or 
offensive stools, demand a careful readjustment of the dietary. 
Three meals, or perhaps four may be taken during the day — 
the intervals between the meals being equal ; and, half an 
hour before each of the meals, two grains of capsicum, with 
one grain of quinine, maybe given in a pill. The breakfast 
should consist of biscuit, dry toast, or stale bread, with fresh 
butter, and perhaps an egg, and one small cupful — not more 
— of hot black tea. Five or six hours after breakfast, and 
half-an-hour after the pill, a dinner of well-done meat, such 
as mutton chops, may be eaten with potatoes — beef-tea, or 
milk being taken for drink, according to taste and the powers 
of digestion. The evening meal may be similar to the morn- 
ing. At first there may be a loathing of all kinds of 
food in the form of regular or " ordinary diets." In such 
cases no meals should be prescribed, and no solid food ; but 
a cup of milk, with a third part of lime-water in it, may be 
given every two hours, prescribed as a medicine ; and a pint 
of beef-tea in divided doses may be taken as a drink during 
the day. This diet may be gradually added to as the appe- 
tite improves. Trousseau observes that " there are some 
chlorotic girls who would rather die from inanition than eat 
ordinary food. We should not hesitate in such cases to 
make those therapeutic concessions which we arc so often 
obliged to submit to in the practice of our art. I allow ali- 
mentary substances acknowledged to be very indigestible — 
caring not for the kind of food so long as it is eaten — as 
radishes, salads, fruits hardly ripe, highly seasoned sausage 
meat, old cheese, vegetables, meats prepared with vinegar, 
acid drinks, and the like. All I require in this whimsical 
diet is, that there be sufficient variety. By such means we 
often succeed in rousing the digestive functions, bringing 
back the sensation of hunger, and gradually leading the pa- 
tient to proper food." Lebert insists on the importance of 
artificial feeding in some cases. A mixed diet is essential. 



CHLOROSIS 53 

Change of air and bathing will also greatly aid in restoring 
health. If the patient lives in a town, she ought to be sent 
into the country ; and, best of all, to the seaside, where sea- 
bathing may be prescribed, if the strength of the patient is 
sufficient. Should the patient have been living in the coun- 
try, a change of air and scene to a lively town, with cheerful 
society ; and, sometimes a little good wine with the food, 
will be no less useful as remedial agents. The much-be- 
quacked use of water, in its varied modes of appliance to 
particular cases, will be found a powerful restorative agent, 
if judiciously used by the patient under medical advice. 

Of medicines, the preparations of iron have most reputa- 
tion. They seem to act by promoting the formation of the 
red blood-corpuscles ;. and they operate best in those cases 
in which the blood is rich in albumen. They also act as 
stimulants to digestion ; and it is not altogether immaterial 
which of the numerous officinal preparations of iron are to be 
prescribed. Almost every physician has some prepara- 
tion of iron he fancies better than another; and some 
of them seem to be aided in their good effects by com- 
bination with carbonate of potash, such as the sulphate 
of iron, in doses of three to five grains, or of the ferri 
sulphas exsiccata, in doses of two to five grains, pre- 
scribed in pills. The use of ferruginous remedies must 
be persevered in for months, and the general indications for 
prescribing the preparations are the same as those given 
under Anaemia. In pills, the iron preparations may also 
be combined with extract of nux vomica, or with strych- 
nia, in suitable doses ; or the syrup of the phosphates 
of iron, quinine, and strychnia, may be gi\en (see Anae- 
mia); or the eliminative action of the colon is to be pro- 
moted by four grains of the pill of aloes and myrrh taken 
every night at bedtime, or by a grain of the watery extract of 
Barbadoes aloes with a little gingerine as a pill. Simple 
bitter tonics are useful adjuncts to the chalybeate treatment, 
such as gentian, calumba, and the preparations of cinchona. 
They aid feeble digestion. Tartarated iron (Ferrum tar- 
taratum) is also a useful remedy, and may be prescribed 
with alkalies, in doses of six to twenty grains, dissolved in 
water. 

Where a high degree of serous plethora exists, and pro- 
duces violent excitement of the vascular system, palpitation 
of the heart, and congestion of the head, venesection maybe 
practised. It not only acts as a sedative, but aids the radi- 



54 CHOLERA, MALIGNANT. 

cal cure of the disease, inasmuch as it causes the subse- 
quently administered ferruginous preparations to be borne 
more easily*. Both general and local blood-lettings may be 
used ; but the blood must be taken in small quantities, a 
couple of ounces at a time being quite sufficient (Vogel). 
Cholera, Asiatic — See Cholera,, Malignant. 

Cholera, Malignant. — Definitio?u — A disease essentially 
specific, existing at all seasons of the year in certain parts of 
India (its perennial endemic area), capable of being propa- 
gated or disseminated over the surface of the earth through the 
atmosphere, or in other ways, but chiefly by means of human 
intercourse between the healthy and the sick. The seizure is 
characterized in many (but not in all), cases by premonitory 
diarrhoea, sudden muscular debility, tremors, vertigo, occa- 
sional nausea, and spasmodic griping pains in the bowels, 
depression of the functions of respiration and circulation, 
and a sense of faintness and oppression in the precordial 
region. A copious purging of serous fluid (alkaline when 
passed, and in appearance resembling water in which rice has 
been washed, sometimes containing blood) is succeeded or 
accompanied by vomiting and burning heat at the stomach, 
coldness and dampness of the whole surface of the body, 
coldness and lividness of the lips and tongue, cold breath, an 
unquenchable thirst, a feeble rapid pulse, difficult and op- 
pressed respiration, with extreme restlessness (a state ex- 
pressed in physiological language by the term " anxietas "), 
suppressed urinary secretion, blueness of the entire surface of 
the body, a sunken and appalling countenance, a peculiarly 
suppressed voice, a peculiar odor from the body, partial heats 
of the prcecordia and forehead — fatal collapse, a reaction 
and secondary fever. Under conditions favorable to its 
propagation malignant cholera often becomes epidemic. 

The College of Physicians defines cholera to be "an epi- 
demic disease, characterized by vomiting and purging, with 
evacuations like rice-water, accompanied by cramps, and re- 
sulting in suppression of urine and collapse."' 

Treatment. — There are few diseases for the cure of which 
so many different remedies and modes of treatment have been 
employed as in cholera. In considering the treatment of this 
disease there are three periods to be provided for, — (i.) The 
period of diarrhoea, which so frequently precedes cholera — 
"premonitory diarrhoea." This indication of intestinal 
trouble must be distinctly recognized as the starting-point of 



CHOLERA, MALIGNANT. 55 

all other symptoms, and the true source of danger. (2.) The 
algide period, or collapse ; and, (3.) Period of reaction. 

(1.) The Period of Premonitory Diarrhoea. — To check or 
arrest the diarrhoea is the practical result aimed at by a va- 
riety of formulae. The evacuations ought to be checked as 
soon as possible. Those in which opium is the main remedy 
have acquired the most amount of confidence. The manage- 
ment of a case embraces the following conditions : — (1.) 
That the horizontal position of the body be maintained ; and 
patients ought to take to bed at once. The necessity for the 
horizontal posture of the patient is, that it aids the efforts of 
the circulative powers, which tend to weakness. (2.) That 
the administration of opium, with or without cordial stimu- 
lants, be at once commenced. With regard to opium, its 
dose must be regulated by, (a.) The extent of the nervous 
prostration ; {b. ) The rapidity of the dejections ; (c.) The 
extent of vascular depletion. In the cases which present 
these phenomena in the extreme a much larger dose of opium 
is required to be given at the outset at one time than in the 
cases less urgent. (3.) That the induction of perspiration be 
brought about. 

The extensive experience of my friend, Dr. Fergus, of 
Glasgow, in whose practice I was privileged to assist during 
the epidemic of 1849, led him to the conclusion (in which I 
concur) that " there is a first stage at which cholera is cura- 
ble and preventible " — namely, that of laxity of the bowels 
previous to vomiting, spasms, or uneasiness of any kind. The 
relaxation of the bowels may not even amount to diarrhoea, 
and may be to the extent of only two or three stools a day, 
where one only was usual. Such relaxation was generally 
thought of no moment, being attended with no pain. On 
the contrary, the evacuations often gave a feeling of relief. 
This is the only stage at which opium is to be given, and 
that in a full dose. At this stage, in combination with a 
stimulant, it is often of the highest value. It is only to be 
given " if the evacuations are still bilious, the pulse fair, and 
the skin warm." When vomiting, " rice-water " purging, and 
cramps set in (the phenomena of collapse) it is then too late 
for opium. Drs. Macpherson and Macnamara record, as the 
result of their extensive experience in India, that if adminis- 
tered at the proper stage no remedy is so effectual as opium; 
and the drug may be safely trusted to cure the premonitory 
diarrhoea of cholera. A dread has arisen of using opium from 
fear of secondary effects ; but the same writers ^ustly observe, 



56 CHOLERA, MALIGNANT. 

that if it has a curative effect, we must not shrink from its 
use from the dread of ulterior consequences. " The vast 
majority of practitioners have found opium extremely useful 
in the early stages of the disease. Men like Twining and 
Parkes, who by no means considered the disease to consist 
merely in vomiting and purging, were agreed that opium is 
the medicine to be given in the commencement of the great 
majority of cases." It calms the brain, relieves the excessive 
feeling of constriction at the epigastrium, tends to counteract 
over-secretion from the mucous membrane, favors cutaneous 
transpiration, and assists the action of such other remedies 
as stimulants, astringents, carminatives, or absorbents (Gub- 
ler). The following formula for pills, each containing a grain 
of opium, with stimulants, is well known as a most useful 
anti-spasmodic pill in the early stage of bowel evacua- 
tion : — 

I£. Pulv. Opii, gr. xii. ; Camphor, gr. xxx. ; Pulv. Capsici, 
gr. ix. ; Spt. vine, rect., q. s. ; Conserv. Rosar, q. s. ; Misce 
et divide in pil. xii. 

Moderate doses of opium or morphine, either alone or 
combined with stimulants (as the pulvis cret?e aromaticus 
cum opio) are sometimes sufficient to check diarrhoea. When 
medical men have charge of large numbers of people, as in 
the army, navy, prisons, workhouses, asylums, hospitals, and 
the like, it is incumbent on them to make frequent inspec- 
tions of those under their care, and to seek out any cases of 
incipient diarrhoea. Responsible officers should be made to 
take notice of those who go more than once a day to the 
water-closet at times when a cholera epidemic influence pre- 
vails. In military practice, frequent inspection of the men is 
of cardinal importance. Every man in a regiment should be 
seen at least three times a day by some medical officer, who 
should also visit the various guards By walking down the 
ranks at roll-call, and picking out the men who show the 
earliest symptoms, cases are thus caught in the stage of pre- 
monitory diarrhoea, and saved. The following rules were 
drawn up by Dr. Fergus, now President of the Faculty of 
Physicians and Surgeons of Glasgow, and printed and hung 
up in prominent places, for the direction and management of 
large numbers of men, in the factories and offices of that city, 
over which he had charge when cholera was epidemic : — 

' (1.) Do not be afraid of cholera, or make it the topic of 
conversation. Fear and all the depressing passions are in- 
jurious. (2.) Do not take brandy ; it is not a preventative ; 



CHOLERA, MALIGNANT. 57 

and it does harm by disordering the action of the stomach 
and bowels. (3.) Do not make any change in your usual 
diet, if it is simple and of easy digestion; take it moderately, 
and at regular intervals, as long fasting is injurious ; and 
carefully avoid excess in any intoxicating beverage. (4.) 
Take no excessive fatigue ; if overheated, beware of any 
sudden chill, and see that the skin is kept comfortably warm. 
If the disease appears in winter, much benefit maybe derived 
from wearing a flannel belt round the body, covering the 
stomach and bowels. (5.) As soon as cholera appears in a 
town, a bottle of solution of morphia or laudanum (and a 
graduated measure) should be kept in every house, place of 
business, factory, or wherever, in fact, there are a number of 
people gathered together. Persons travelling should always 
have it with them, or easy of access. During the existence 
of the epidemic, one person in each factory, &c, should take 
the charge of the health of the inmates, and should act as 
' house physician,' warning all under his or her care to at- 
tend to the slightest relaxation of the bowels. He should 
remind them that the less pain the more danger, and there- 
fore the more need of immediate and energetic action. (6.) 
Should the slightest diarrhoea occur, the individual so attacked 
should at once receive forty minims of solution of morphia 
or laudanum.* If from home or at business, the patient 
should be at once conveyed home in a cab, put to bed, and 
kept warm. If chilled, warm water bottles may be put to 
the feet. If the first dose has not checked the looseness, 
the patient should take a second, and then have a flannel 
cloth thoroughly dipped in turpentine, placed all over the 
stomach and bowels for from forty minutes to an hour, or a 
large, soft, warm poultice of linseed meal and mustard for 
one or two hours. If the second dose has not effectually 
checked the diarrhoea, and medical assistance has not arrived, 
a third dose may be taken. (7.) The patient must remain in 
bed two or three days after the diarrhoea is checked. I insist 
strongly on this, for the patient often feels so well that it is 
difficult to get him to attend to it. (8.) To relieve the thirst, 

* If a measure is not at hand, a small teaspoonful. Of course this 
dose is for adults. Below that age the doses should be a drop for each 
year till twelve or fifteen, and after fifteen a drop and a half for each 
year, up to forty minims, or a small teaspoonful. More portable than 
laudanum, and of equal efficacy, would be pills composed of a grain and 
a half of opium, and a grain of cayenne pepper in each pill, three of 
which may be taken with safety, till medical assistance arrives. 



58 CHOLERA, MALIGNANT. 

a piece of ice may.be given, or a mouthful of iced water, or 
soda water ; but in no case must more fluid be taken at a 
time, and all food should be abstained from till from fifteen 
to eighteen hours after the opiate has been administered. 
Then, and for two or three days, the diet should consist of 
such food as rice, sago, arrowroot, Indian corn flour, tea and 
toast, &c. ; about the third day beef-tea or chicken-soup 
might be taken. (9.) These rules are for the first stage, and 
for it only — i. e., the diarrhoea. If a person has neglected the 
first warning, and is in the second stage — /. e. y has cramps, 
vomiting, and stools like rice-water, without smell — you 
should, till medical assistance arrives, place the patient in 
bed surrounded with bottles of hot water, and give him a 
little ice, and mouthfuls of soda and water. If the cramps 
are severe, you must rub the limbs with turpentine, or chlor- 
oform and oil." — -Glasgow Med. Journal, 1866. 

The following cholera mixture (as it was called) was pro- 
posed by the Board of Health during the prevalence of 
cholera, and was no doubt useful in many cases of diarrhoea: 

I£ Pulveris Arom., 3 iii- ; Tinct. Catechu, f 3 x. ; Tinct. 
Cardam. Comp., f3vi.; Tinct. Opii, 3i-> Mist. Cretse, pre- 
parat. ad f \ xx. Of this mixture the dose is one ounce. 

Bulky doses of remedies are obviously objectionable. The 
usual remedies known as " astringents" (compared with each 
other, or with opium) have no decided influence for good. 
"Astringents," as such, have merely a negative effect. 

Of the various preparations of opium, Dr. Macnamara 
gives preference, as Dr. Fergus does, to the tincture. Thirty 
drops of laudanum in water should be administered as soon 
as possible after the first watery motion has been voided, and 
this dose must be repeated if the purging does not stop after 
the first dose has been given. A pill composed of one grain 
of opium and two grains of the acetate of lead, to be taken 
every hour till the purging stops, is a useful formula, and 
more easily distributed than laudanum. Supposing thirty 
drops of laudanum to have been administered ; and, that 
within half an hour the patient is again purged, Dr. Macna- 
mara does not hesitate to repeat the dose at once. It is not 
advisable to wait until two or three motions have been passed. 
Watery painless purging should be at once stopped by such 
means. When the disease is endemic, and still more so when 
it is epidemic, every family should have a bottle of laudanum, 
to be resorted to at once after the first watery motion. If 
the motion is accompanied by a feeling of exhaustion, and a 



CHOLERA, MALIGNANT. 59 

faintish sensation at the prsecordial region, the dose of laud- 
anum should be followed by " a stiff glass of brandy and 
water." " No more erroneous practice can possibly exist in 
India, or any other place where cholera exists, than that of 
allowing diarrhoea to go on upon the supposition that the 
attack is a bilious one, and that the purging is a salutary or a 
harmless process. More deaths from cholera have been 
occasioned from this than from any other mistaken notion on 
this subject. The issue is simply this: Supposing the attack 
to be a bilious one, we stop it with opium, and may subse- 
quently have to administer a dose or two of blue pills and 
rhubarb ; or, perhaps, a little judicious starving may answer 
the same purpose. But if, under the impression that the 
diarrhoea is bilious, we allow it to run on, it may become, in 
the course of a few hours, the second stage of cholera, and 
our opium may then be of little or no use." 

In the case of children the dose of laudanum must be 
regulated by the age of the child. 

But there are certain cases in which, although the diar- 
rhoea may be altogether checked by such remedies, yet the 
disease is not cured. Symptoms characteristic of the algide 
or collapse stage supervene. These are the cases which have 
been held to justify that method of treatment which has for 
its object elimination by the promotion of purging and of 
vomiting — excretion of the poison by the alimentary canal. 
The advocates of this method of treatment also lay stress up- 
on the fact that those are the worse cases in which the diar- 
rhoea is the least; and that those cases are the most hopeful 
in which diarrhoea and vomiting are the most severe. Dr. 
George Johnson's treatment by castor-oil has for its object 
the elimination in this way of the specific poison; and it may 
be said of it, that it is neither more nor less successful than 
other remedies of its class. It, as well as purely astringent 
mixtures, excites such loathing in most cases that it cannot 
be persisted in. Dr. Johnson agrees that " diarrhoea during 
an epidemic season ought not to be neglected even for an 
hour." He regards such diarrhoea as an indication of the 
presence of offending material in the alimentary canal — e.g., 
(1.) Unwholesome, undigested food; or, (2.) A large and 
unnatural accumulation of the feculent contents of the 
bowel ; or, (3.) Noxious secretions poured from the blood 
into the bowels, in consequence of the action of a specific 
blood-poison. To this latter process Dr. Johnson believes 
choleraic diarrhoea to belong. Therefore he lays down the 



6o CHOLERA, MALIGNANT. 

following rule: — " Not to attempt by opiates, or by other 
directly repressive means, to arrest a diarrhoea while there is 
reason to believe that the bowel contains a considerable 
amount of morbid and offensive material; for, such offensive 
material must come forth before diarrhoea can permanently 
cease." Purging he considers the natural way of getting rid 
of the irritant cause; and the safest purgative he believes to 
be castor-oil. So far as meeting the conditions of examples 
(i.) and (2.) as above stated, the treatment cannot be im- 
proved upon; but that it is the best possible treatment to 
meet the preliminary diarrhoea or relaxation of the bowels in 
cholera cannot be regarded as established nor warranted 
by what we know of the pathology of the disease as set forth 
in the text. Assuming it to be proven that malignant cholera 
is a specific disease in which there is poisoning of the 
blood; and believing, as I do, that such is the pathology of 
the disease; and, seeing that the College of Physicians enter- 
tain a similar belief — for malignant cholera has been classed 
by the College in Section A of the General Diseases, con- 
cerning which it is written, that " it comprehends those dis- 
orders which appear to involve a morbid condition of the 
blood, and which present the following characters: — they run 
a definite course, are attended with fever, and frequently 
with eruptions on the skin, and are more or less communi- 
cable from person to person." Assuming the pathology of 
malignant cholera to be as here represented, I cannot admit 
that the best indications for the treatment of the disease are 
those which suggest an attempt to eliminate the poison by 
the promotion of purging and vomiting. I do not believe 
we can, by any remedy, nor by the over-stimulation of any 
eliminative function, ever get rid of any such poisons as 
those of small-pox, measles, scarlet fever, typhus fever, en- 
teric fever, or any other general and specific disease-poison 
comprehended in Section A. No method of treatment, 
based on the so-called principle of eliminating a poison, has 
ever effected a cure of any one of these diseases; and I do 
not see any likelihood of the principle being more successful 
in cases of malignant cholera than with other diseases of the 
class. We have never yet been able to '" cut short " any of 
these diseases by emetics, purgatives, or diaphoretics. Nei- 
ther emetics nor purgatives have ever cut short small-pox, 
although, if we are to follow indications of treatment elimin- 
ative of poison, we ought to encourage such vomiting and 
purging which mark the initiative stage of most of the ex- 



CHOLERA, MALIGNANT. 6l 

anthemata. The early attempts to cure small-pox, scarlet 
fever, and measles, by promoting copious eruption on the 
skin, in the belief that the poison was so eliminated, proved 
a signal failure. The popular belief that " better out than 
in " was not found to be a safe principle of treatment in the 
management of those diseases. We have no eliminativc 
method of treatment which will rid the blood of such 
specific disease-poisons; just as we have no antidote which 
will destroy or counteract the influence of snake-vemon 
when once it has got accidentally or artificially into the blood. 
We do our best when we try only to guide the patient 
through those specfiic diseases, by moderating the violence 
of the expressions of the malignant phenomena, not by in- 
creasing them. We cannot cure these diseases. The most 
successful results in the treatment of all of them have been 
got by those agencies which have led to modified and less 
malignant forms of disease, such as by vaccination, in regard 
to small-pox, and by sanitary improvements generally. We 
do not think of, and dare not attempt to promote, diarrhoea 
or specific lesion in the intestines during enteric fever. Why 
should we be induced to promote diarrhoea in malignant 
cholera, in the belief that we are thereby to free the blood 
from the specific poison of the disease ? We have no evi- 
dence that the body is freed of the poison in this way. 
The bowel discharges may be, and undoubtedly are, means 
(but not necessarily the only means) of propagating the 
disease; but it does not follow that promoting their dis- 
charge frees the blood from poison either in enteric fever 
or in cholera. By moderating the catarrhal flow in enteric 
fever, it is not found that we aggravate the disease and 
lock up specific poison in the system; certainly by mod- 
erating, curtailing, or restraining the diarrhoea of cholera, 
the only chance is left us of guiding the patient through 
that disease; and OPIUM is the remedy which, by actual 
experience, alike in India and in this country, seems most 
worthy of reliance; but, — only at the commencement of 
laxity, or relaxation of the bowels, in seasons when chol- 
era is epidemic. 

Treatment based upon conflicting theories (which are 
but theories after all) as to the nature of the disease, is 
greatly to be deprecated; and on this point Dr. Fergus 
makes the following pertinent remarks: — 

" The influence of the theories of Dr. G. Johnson and 
others is to be seen in the instructions recently issued by 



62 CHOLERA, MALIGNANT. 

the Board of Supervision in Scotland — very excellent as to 
the sanitary part, but in the medical portion (like most 
things issued by a committee) an evident compromise. It is 
a compromise, I believe, between the facts and a theory. . . 
. . We are told, under the fourth section, to take castor oil 
or rhubarb and soda for looseness of the bowels, and after- 
wards the astringent mixture or pills — the former being in- 
tended as eliminators to promote the diarrhoea, the latter to 
check it. If this advice is followed during an epidemic of 
cholera, the consequences may be very serious. It is well 
known that during an epidemic there is a general tendency 
to relaxation of the bowels, and that they become very sus- 
ceptible of the smallest dose ol even the mildest medicine. 
Any one who has had much to do with cholera must have 
frequently met with cases which appeared to be the direct 
consequence or result of a slight dose of medicine. The 
risk is that the castor-oil and rhubarb would drive most of 
the cases into the second stage of cholera, and then the use 
of astringents and opiates at that stage would increase the 
danger immensely. As to the remedies ordered, the quan- 
tity of laudanum — viz., five drops per dose — is too small, and 
there is no necessity for the chalk and catechu. Before the 
opiate could produce much effect, the stomach would be 
overloaded with the chalk and catechu, to the extent of in- 
ducing vomiting. The pills should be ordered after each 
discharge from the bowels; but people will find it easier to 
provide themselves with laudanum than to use complicated 
mixtures or pills." 

"With regard to castor-oil," writes Dr. Macnamara, " I was 
acting as House Physician to King's College Hospital, in 1854, 
when Dr. G. Johnson was treating his cholera patients on 
eliminative principles. I caught some of his enthusiasm on 
the subject, and came out to India the same year full of con- 
fidence and hope in castor-oil. These ideas were destined 
soon to pass through a severe ordeal; for in the following 
year I was left at Bhaugulpore in charge of a field hospital. 
I was the only medical man in the place, when cholera burst 
out among the Europeans and natives under my care: I 
went boldly to work with castor-oil, but it absolutely and 
completely failed; the mortality from the disease was fearful. 
I have since on several occasions tried castor-oil in cholera, 
but I have now finally abandoned it, having never seen any 
benefit arise from its use." In the second oralgide stage the 
object is to promote reaction and to keep it in moderation. 



CHOLERA, MALIGNANT. 63 

If the patient is not seen till profuse discharges — rice-water- 
like — have taken place, the time for all active treatment has 
passed, and efforts must be directed solely to restoration and 
repair; and, if possible to rendering the stools acid, by the 
following draught every half hour for four hours, and then 
to continue every hour (Macnamara): — 

3. Dilute sulphuric acid, and dilute acetic acid, of each 
m xv.; carbolic acid, half a drop; water, an ounce and a 
half; and opium may be added to the first and second doses, 
as existing circumstances may indicate. 

To promote reaction in cholera and diarrhoea, the follow- 
ing formula has met with most universal approval in this coun- 
try and in India. So highly is it valued, indeed,that it is or- 
dered to be always in store, and in readiness in the " Medical 
Field Companion " of the army when on the march: — 

P^. 01. Anisi., 01. Cajeput, 01. Juniper, aa 3iss,; vEther., 
§ ss.; Liquor Acid. Halleri, 3 ss. ; * Tinct. Cinnam., § ii.; 
misce. The dose of this mixture is ten drops every quarter 
of an hour in a tablespoonful of water. An opiate may be 
given with the first and second dose, but should not be contirr*- 
ed, for reasons already given. 

The nitrite of amyl has also been recommended in the 
collapse of cholera by several physicians. It ought to be 
given internally, or by subcutaneous injection rather than by 
inhalation (Dr. T. L. Brunton, Brit. Med Journ., of Jan. 13, 
1872). The indications generally followed are to treat the 
case as we should a similar state in typhoid fever, and to 
moderate the affection of the bowels by milk opiates, by ene- 
mata, and by sinapisms to the abdomen; also, to relieve the 
head by leeches and cold lotions, and subsequently, as the 
tongue becomes brown, to support the patient with wine, 
sago, strong broths, and a generally cordial treatment. 
During the reaction stage Dr. Andrew Clark, of the London 
Hospital, employed with great success a powder composed as 
follow: — 

Hyd. c. Creta, gr. ii. ; Pulv Ipecac, gr. ss. ; Pulv. Doveri, 
gr. iiss. ; night and morning. 

The cases most benefited by this remedy were those in 
which the tongue had become dry and hard, salines, lemon- 
ade, and chlorate of potash drinks being freely given. Mus- 

* The Liquor or Elixir Halleri consists of one part of concentrated 
sulphuric acid to three parts of rectified spirit. It is commonly employ- 
ed in Germany in the treatment of typhus and allied diseases, in doses of 
five to twenty drops in solution (Murchison, 1. c, p. 266). 



64 CHOLERA, MALIGNANT. 

tard plasters or blisters to the nape of the neck were found to 
be of use by inducing the return of the urinary secretion. 

The sick-room should be supplied with fresh air. Liquids 
should be assiduously applied to every surface capable of 
absorbing them, and the patient should be suffered to remain 
as free from officious treatment as possible. Heat applied in 
the dry form is to be avoided, but cloths moistened with hot 
water may be applied; or the patient may be wrapped up in 
warm, moist blankets, and hot bottles or bags of heated sand 
placed around his cold and benumbed body. After the 
temperature is restored, the surface should still be kept moist, 
by sponging from time to time, or by the use of the wet sheet, 
to moderate the reaction. Urgent thirst is one of the most 
distressing symptoms in cholera. There is incessant craving 
for cold water — doubtless instinctive, to correct the inspis- 
sated condition of the blood, due to the rapid escape of the 
liquor sanguinis. It was formerly the practice to withhold 
water — a practice as cruel as it is mischievous. Water in 
abundance, pure and cold, should be given to the patient, 
and he should be encouraged to drink it, even should a large 
portion of it be rejected by the stomach; and when the pur- 
ging has ceased, some may, with much advantage, be thrown 
into the bowel from time to time (Maclean). Niemeyer re- 
commends cold wet compresses to be frequently laid over 
the abdomen; and, also a grain of calomel every hour. Such 
compresses are said to be grateful to the feelings of the pa- 
tient, whose sense of heat is great, although he may be cold to 
the bystander. The practice also is consistent with the lesions, 
especially the intensely pink vascularity seen in the intestines 
after death. The following as a drink is generally relished 
and retained upon the stomach: — "A raw egg beat up with 
half a pint of milk, and then mingled with about a pint and 
a half of water, adding as much salt as will give the whole an 
agreeable taste " (Dr. Andrew Buchanan,). Or whey, milk 
and water, weak chicken soup, or any similar decoction, may 
be drunk ad libitum. Enemata of warm milk, repeated as 
often as expelled, are of the highest importance if the evacu- 
ations have ceased, by supplying an absorbable fluid, by miti- 
gating abdominal pains, and diluting acid secretions. The 
secreting of mine may be promoted by dry cupping over the 
loins, by the me cf solution of chlcrate of potash, and the 
like. But suppression of this secretion is most to be 
dreaded where opium has been too freelv used in the 
treatment 



CHOLERA, MALIGNANT. 65 

In men of intemperate habits we often see, during the stage 
of reaction, obstinate vomiting of thick, tenacious, green 
paint-looking matter, probably bile-pigment, acted on by 
some acid in the stomach orailmentary canal. It is a symp- 
tom of evil omen, and often goes on uncontrolled until the 
patient dies exhausted, and this although all other symptoms 
may promise a favorable issue. It may last for a week, re- 
sisting all remedies, and proving fatal when the urinary secre- 
tion has been restored, and all cerebral symptoms have sub- 
sided. Alkalies in the effervescing form, free stimulation of 
the surface, and chloroform in small doses, offer the best 
hope of relief for such cases. The patien,t should be nourish- 
ed more by the bowel than the stomach when vomiting is 
present. Ice should be given ad libitum, where it can be 
obtained, not only to dissolve in the mouth, but to swallow 
in pieces of convenient size (Maclean). 

A plan, perhaps peculiar to this country, which was prac- 
tised to bring about reaction (when the inefficiency of medi- 
cines was generally admitted), was an injection into the veins 
of the patient of a solution of half an ounce of muriate of 
soda, and four scruples of sesquicarbonate of sod?, in ten 
pints of water, at a temperature varying from 105 to 120 
Fahr. This solution was injected slowly, half an hour being 
spent in the gradual introduction of the ten pints, and the 
immediate effects of this treatment were very striking. The 
good effects were rapid in proportion to the heat of the solu- 
tion, but a higher temperature than what is stated could not 
be borne. After the introduction of a few ounces, the pulse, 
which had ceased to be felt at the wrist, became perceptible, 
and the heat of the body returned. By the time three or four 
pints had been injected, the pulse was good, the cramps had 
ceased, the body, that could not be heated, had become warm, 
and instead of a cold exudation on the surface, there was a 
general moisture ; the voice — before hoarse and almost ex- 
tinct — was now natural ; the hollowness of the eye, the 
shrunken state of the features, the leaden hue of the face and 
body had disappeared ; the expression had become animated, 
the mind cheerful, the restlessness and uneasy feelings had 
vanished ; the vertigo and noises of the ear, the sense of op- 
pression at the praecordia, had given way to comfortable feel- 
ings ; the thirst, however urgent before the operation, was 
assuaged, and the secretion of urine restored, though by no 
means constantly so. But these promising appearances were 
not lasting : the vomiting continued, the evacuations became 
5 



66 CHOLERA, MALIGNANT. 

even more profuse, showing that the remedy did not touch 
the root of the evil. The patient soon relapsed into his 
former state, from which he might again be roused by a rep- 
etition of the injection. This amendment, however, was 
transient, and the fatal period was not long deferred. Of 156 
patients thus treated at Drummond Street Hospital, Edin- 
burgh, only twenty-five recovered, — a lamentably small pro- 
portion ; and small as it is, it seems doubtful if the recover- 
ies were final or complete (Mackintosh, " Principles of Pathol- 
ogy," p. 365). Nevertheless, injection of fluid by the^ veins 
. ought still to be persevered in as a remedy in the .right direc- 
tion — with due regard to temperature — as a means of pro- 
longing life. A trial made by Surgeon-Major E. Y. Kellat 
at the close of an Indian epidemic is deserving of more ex- 
tended experience, namely : — To inject distilled water at a 
temperature of 99° Fahr. hypodermically, into the connec- 
tive tissue of the body, or into the cavity of the peritoneum. 
He thus aimed at establishing an artificial anasarca or an as- 
cites ; experience having shown that of several instances of 
cholera attacking persons suffering from such conditions, the 
effused fluid became rapidly absorbed during the course of 
the cholera — the patients recovering. The distilled water he 
thus proposes to inject hypodermically, must filter through 
the living tissue before it can reach the circulation ; and 
hence be more fitted to mingle with the blood, than when 
thrown into the veins directly from contact with air. Water 
is the cardinal want. The supply of it fails first : and thus 
introduced it avoids contact with the morbid surface and se- 
cretions of the stomach and bowels, which are barriers to its 
absorption in that direction. 

Stimulants tend to irritate the stomach, and are of no use 
in exciting the heart to any salutary action. Employed as 
in. typhus, they are worse than useless. All violent remedies 
are greatly to be deprecated. Strychnia, prussic acid, to- 
bacco, galvanism, boiling water, the actual cautery, or firing 
the spine, or bags of ice to the spine, or injections of spirits, 
are proven by trials to be of no use ; nor can their recom- 
mendation be supported except upon baseless theories, hav- 
ing no rational relation to the pathology of the disease. 

To generalize on the subject of remedies in cholera, the 
broadest conclusion seems to be, that remedies with an acid, 
rather than an alkaline or neutral reaction, have been the 
most beneficial. 

Prevention of Cholera. — The following summary, from the 



CHOLERA, MALIGNANT. 6j 

writings of Dr. Parkes and Mr. Simon, will best conclude 
this account of cholera. The importance of the topics noticed, 
and the uncertainty that yet enshrouds many of them, may 
justify, it is hoped, the amount of space which the subject 
has taken up: — 

" For the first time in the history of cholera a new system 
of prevention has been brought largely into play in Europe — • 
viz., the addition to the discharges of a presumed disinfect- 
ing substance. This plan, of course, is based on the belief 
that the principal (perhaps the only) mode of spread is by 
means of the putrefying evacuations ; and the results ob- 
tained by it give certainly some strong evidence in favor of 
this opinion. In this country the difficulty has been to make 
the public (and, in some cases, even the medical men) sensi- 
ble of the importance of this plan, and of the necessity of 
giving it a complete trial. In some cases in which it has 
really been fairly tested, it appears to have arrested the spread 
of the disease, as at Bristol ; and Dr. Budd's paper in 
the Brit. Med. Journ., April 13, 1867, gives good 
evidence on this point. In Southampton also, I be- 
lieve, the spread was limited in this way, though it was not 
arrested so perfectly as at Bristol. In London, and several 
provincial towns, the method was also tried more or less fully. 
In Germany, owing to the influence of Pettenkofer, the dis- 
infecting plan was also brought into play, and the system fol- 
lowed has been described by that chemist.* Without ana- 
lyzing all the evidence, I proceed to give the most important 
practical rules. The dangerous period of the choleraic 
stools is supposed to be when they become very ammoniacal. 
This occurs sometimes immediately they are passed, but 
usually not to any extent for some time. It is thought (but 
of course exact scientific proof is not readily attainable) that 
anything which makes and keeps them acid prevents the 
changes which cause the poison. The three principal means 
of doing this are the use of carbolic acid, and sulphate of iron 
(with or without permanganate of potassium), and the salts 
of zinc. Each has its advantages, and all may be used. The 
carbolic acid, from its liquid form and from its volatility, is 
excellently adapted to purify air, and to be used when sur- 
faces are to be washed. It is also useful for sewers and 
closets. The sulphate of iron in substance and strong solu- 

*" Cholera Regulativ, " von H. Griesinger, M. Pettenkofer, and C. 
A. Wunderlich, Zietschrift. fur. Biologie, Band, II., p. 435. 



68 CHOLERA, MALIGNANT. 

tion is better adapted for being put in the utensils in a room, 
as it has no smell, but it may be equally used for sewers and 
for watering streets. The sulphate of zinc (for the chloride 
is too dear) is better adapted for being put on linen or on 
floors, as it does not ironmould the linen like the sulphate of 
iron. The carbolic acid has not been used much in Ger- 
many, as it is still too dear; but Pettenkofer makes an ob- 
servation of importance — viz., that when added to sulphate of 
iron the mixture seems to have more power of preventing 
ammoniacal development than either substance separately. 
If so, it might be desirable, as a matter of practice, to use 
the two together as much as possible. The salts of zinc 
(sulphate or chloride) may be also used, but are perhaps not 
so good, and in some forms are dearer than the iron salts. 
Chloride of lime does not prevent the ammoniacal change, 
and appears altogether less useful. The quantity in which 
these substances must be used is as follows: — For each 
healthy person, daily, about three-quarters of an ounce of 
sulphate of iron, or one drachm of strong (but impure) car- 
bolic acid, is sufficient. This amount will entire'y prevent 
any decomposition of the fasces for several days. In a town, 
therefore, where sewers are used, the above amount of sul- 
phate of iron, or carbolic acid, multiplied by the number of 
persons, should go into the sewers daily, and, if possible, 
should be passed in from the houses, so as to act on the 
house-drains as well as on the main sewers. If the place is 
not sewered, then the disinfectants should be added to the 
cesspools, middens, latrines, or whatever plans may be in use. 
If both sulphate of iron and carbolic acid are used, which is 
to be recommended, half the quantity of each should be 
employed. The iron should be dissolved in a good deal of 
water. 

" In Southampton, is 1866, carbolic acid was chiefly used; 
and the average amount was about twenty gallons daily for 
a town of 50,000 people: it certainly appeared useful. If an 
aerial disinfection is needed, sulphurous acid (obtained by 
burning sulphur) is perhaps the best. Nitrous acid fumes 
are certainly very powerful; and one or other of these sub- 
stances should be used for half an hour daily in all privies or 
latrines. For washing clothes the iron salts are not ap- 
plicable, as they stain linen. Carbolic acid gives a disagree- 
able smell. Either a watery solution of sulphurous acid, or 
a solution of zinc salts, should therefore be used. Baking 
the clothes, at a temperature of 250 , or boiling, should be 



CHOLERA, MALIGNANT. 6q 

used. In hospital wards, dead-houses, &c, it is a good plan 
to sprinkle sawdust on the floors, and to moisten it with the 
weak carbolic acid (one part of crude acid in sixty or eighty 
of water). These measures should be commenced when 
cholera is apprehended. Every privy and sewer should have 
twice daily the mixed carbolic acid and sulphate of iron so- 
lution. If cholera is introduced, the amount should be 
doubled in the privies of all the adjacent houses, while the 
closet of the affected house should never act without a por- 
tion of the disinfecting liquid being placed in it. If the dis- 
ease breaks out, a plan recommended by Dr. Budd is worthy 
of imitation — viz., to place a layer of carbolic acid powder 
(carbolic acid and lime) in the bed, under the breech of the 
patient. The disinfection in this way of the closets and 
privies of hotels, railways, and workshops, should be com- 
menced very early." 

A saline antiseptic, " chloralum, has been recently much 
commended; and on the subject of prevention Mr. Simon 
has also made some valuable suggestions: — ■ 

" Wherever cholera is known to exist too much importance 
cannot be attached to the precaution of thoroughly disin- 
fecting, without delay, all discharges from the stomach and 
bowels of persons suffering under the disease, and of disin- 
fecting or destroying all bedding, clothing, towels, and the 
like which such discharges may have imbued; and, of course, 
neither choleraic discharges, nor any slops which may con- 
tain traces of them, should ever (even when supposed to be 
disinfected) be cast into any position, from which they may 
get access into drinking water. But, although the duty of 
observing those precautions is one which ought never to be 
neglected, populations cannot prudently stake their lives on 
the chance that it will be completely fulfilled for them. 
Apart from all questions of negligence, the degrees of cholera 
are too many, and the slight and incipient cases far too apt 
to escape observation, for any such defence against its infec- 
tion to be more than partial. And, therefore, the main object 
for endeavor must be to secure everywhere such local cir- 
cumstances that the infective material, though not disin- 
fected, would be unable to spread its influence among the 
population. The dangers which have to be guarded against 
as favoring the spread of cholera infection are particularly 
two. First, and above all, there is the danger of water sup- 
plies which are in any (even the slightest) degree tainted by 
house refuse or other like kinds of filth: as where there is 



fO CHOLERA, MALIGNANT, 

outflow, leakage, or nitration from sewers, house-drains, 
privies, cesspools, foul ditches, or the like into springs, 
streams, wells, or reservoirs from which the supply of water 
is drawn, or into the soil in which the wells are situate; a 
danger may exist on a small scale (but perhaps often re- 
peated in the same district) at the pump or dip-well of a 
private house, or, on a large and even vast scale, in the source 
of public waterworks. And secondly, there is the danger of 
breathing air which is foul with effluvia from the same sorts 
of impurity. 

" Temporary security must, as far as practicable, be sought 
in measures of a palliative kind: — (a.) Immediate and search- 
ing examination of sources of water-supply should be made 
in all cases where the source is in any degree open to the 
suspicion of impurity; and the water both from private and 
public sources should be examined. Where pollution is dis- 
covered everything practicable should be done to prevent 
the pollution from continuing, or, if this object cannot be at- 
tained, to prevent the water from being drunk, (b.) Sim- 
ultaneously there should be immediate thorough removal of 
every sort of house refuse and other filth which has oc- 
cumulated in neglected places; future accumulations of the 
same sort should be prevented; attention should be given to 
all defects of house-drains an i sinks through which offen- 
sive smells are let into houses; thorough washing and lime- 
washing of uncleanly premises, especially of such as are 
densely occupied, should be practised again and again, (c.) 
Disinfection should be very freely and very frequently em- 
ployed in and round about houses wherever there are re- 
ceptacles or conduits of filth, wherever there is filth-sodden 
porous earth, wherever anything else, in or under or about 
the house, tends to make the atmosphere foul. 

" In the absence of permanent safeguards no approach to 
security can be got without incessant cleansings and disin- 
fections, or without extreme and constant vigilance against 
every possible contamination of drinking-water." 

Then again as to the risk of contagion, Mr. Simon writes : 

" Cholera in England shows itself so little contagious, in 
the sense in which small-pox and scarlatina are commonly 
called contagious, that, if reasonable care be taken where it 
is present, there is almost no risk that the disease will spread 
to persons who nurse and otherwise closely attend upon the 
sick. But cholera has a certain peculiar infectiveness of its 
own, which, where local conditions assist, can operate with 



CHOLARA, MALIGNANT. 7 I 

terrible force, and at considerable distances from the sick. 
It is characteristic of cholera (and as much so of the slight- 
est choleraic diarrhoea as of the disease in its more developed 
and alarming forms) that all matters which the patient dis- 
charges from the stomach and bowels are infective. Probably, 
under ordinary circumstances, the patient has no power of 
infecting other persons except by means of these discharges, 
nor any power of infecting even by them, exeept in so far as 
particles of them are enabled to taint the food, water, or air 
which people consume. Thus, when a case of cholera is 
imported into any place, the disease is not likely to spread, 
unless in proportion as it finds locally open to it certain fa- 
cilities for spreading by direct infection. In order rightly to 
appreciate what these facilities must be, the following con- 
siderations have to be borne in mind : — First, that any chol- 
eraic discharge, cast without previous thorough disinfection 
into any cesspool or drain, or other depository or conduit of 
filth, infects the excremental matters with which it there min- 
gles, and probably more or less, the effluvia which those mat- 
ters evolve ; secondly, that the infective power of choleraic 
discharges attaches to whatever bedding, clothing, towels, 
and like things have been imbued with them, and renders 
these things, if not thoroughly disinfected, as capable of 
spreading the disease in places to which they are sent (for 
washing or other purposes), as, in like circumstances, the pa- 
tient himself would be ; thirdly, that if, by leakage or soak- 
age from cesspools or drains, or through reckless casting out 
of slops and wash-water, any taint (however small) of the in- 
fective material gets access to wells or other sources of drink- 
ing-water, it imparts to enormous volumes of water the power 
of propagating the disease. When due regard is had to these 
possibilities of indirect infection, there will be no difficulty 
in understanding that even a single case of cholera, perhaps 
of the slightest degree, and perhaps quite unsuspected in its 
neighborhood, may, if local circumstances co-operate, exert 
a terribly infective oower on considerable masses of popula- 
tion." 

The inquiries made through the Epidemiological Society 
show that special hospitals, or special wards m hospitals, 
ought to be devoted (with a separate and special staff of at- 
tendants for day and night duty, or more frequent periods of 
relief) entirely to the management of cholera patients. 

With regard to India much may still be expected from a 
thorough improvement of its sanitary condition : and espec- 



72 CHOLERA, SIMPLE. 

ially of the filthy towns and bustees, or native villages, con- 
structed without any plan or arrangement, without roads, 
without drains, ill-ventilated, and never cleaned — the abodes 
of misery, vice, and filth — the nurseries of sickness and dis- 
ease. These are the localities within the endemic area of 
cholera which require special attention and improvement in 
the first instance ; and which are now receiving the attention 
of the Indian authorities through their special sanitary ad- 
ministration. 

Cholera, Simple. — Definition. — An acute catarrhal in- 
flammation of the mucous membrane of the stomach, which 
extends into the intestines, attended with nausea, retching, 
and vomiting, followed by severe watery diarrhoea, consisting 
of profuse transudation of fluid "containing little albumen ; 
the whole system generally being affected, as evidenced by 
fever. 

Treatment. — If the stomach retains undigested food be- 
lieved to be unwholesome, a mild emetic may be given ; but 
this is rarely necessary, as the stomach usually empties itself 
completely. When the solid matters have been ejected, the 
subsequent treatment will depend on the acidity or acrid 
nature of the matter ejected. Simple alkaline remedies, like 
carbonate of soda in solution ad libitum, will sometimes re- 
lieve the nausea and sickness ; and when the vomiting be- 
comes liquid, opium is the remedy most to be relied upon. 
It must be, however, given in solution, such as laudanum, 
Battley's solution, or with chloroform and other stimulants, 
as in the form of chlorodyne. A full dose of either of these, 
or a full dose of muriate of morphia, laid on the tongue, 
should be administered immediately after the act of vomit- 
ing. If the first dose should be immediately rejected, a sec- 
ond is to be repeated ; if that too is rejected, a third may be 
so given, but no more. An enema of laudanum, one to two 
drachms, with starch must be given instead, directly after an 
evacuation of the bowels. If this is rejected after being again 
repeated, then hypodermic injection of solution of morphia 
may be adopted ; and in any form when retained, the remedy 
will require repetition every hour or half hour till the vomit- 
ing and purging are arrested. The effects of each dose must 
be carefully watched, so that narcotism may not be induced. 
It is important that so much fluid may not be taken as the 
greatness of the thirst desires. A table-spoonful of ice-cold 
water, given at short intervals, or a bit of ice to dissolve in 



CHOREA. 73 

the mouth, is all that ought to be permitted. Gruel made 
from the boiled fluid in which oatmeal has been soaked, and 
allowed to cool, and given with ice, is a grateful and sooth- 
ing drink. 

Chorea. — Definition. — An irregular spasmodic convulsive 
action of the voluntary muscles, ceasing during sleep, of a 
clonic kind, especially a profusion of movements of the face 
in smiles and frowns, and of the trunk and extremities in 
gesticulations. The movements are either entirely withdrawn 
from the control of volition, or but little under the direction 
of the will. The disease is brought on by fear or emotion, 
or without obvious exciting cause. It has special relation 
to certain other nerve-disorders, also to rheumatism and to 
heart affections. 

Treatment. — Having ascertained a time limit to the dis- 
ease we are able to judge as to the effect of medicinal 
remedies, observing by how much they shorten its duration. 
The remedies given may be classed into three divisions : (i.) 
Anti-rheumatic remedies, as potash, iodides, bark ; (2.) 
nervine tonics, arsenic, zinc, iron ; (3.) empirical, as ice or 
ether over the spine, galvanism, sedatives. 

From the use of ether to the spine — a plan so strongly 
commended by a few — Dr. Andrew Clark has seen no bene- 
fit. In his experience rest and the free use of arsenic are 
the remedies which shorten most the duration of the disease. 
Arsenic, in the form of Fowler's solution, is also well 
spoken of by Romberg, in doses of three to five drops. Dr. 
Bristowe also is in favor of arsenic, given in small* doses, and 
continued for some length of time. Experience also shows 
that, in most simple cases, any special treatment by drugs 
may be dispensed with ; and that the chief matter to attend 
to is the general health and nutrition of the patients, which 
may be sufficiently dealt with by good diet, the withdrawal 
from causes of excitement and annoyance, and by discipline 
and sensible management. There are, however, various 
drugs which may prove valuable auxiliaries ; as, for instance, 
the salts of iron when there is anaemia, and in all cases cold 
or tepid bathing ; or the cold douche to the spine, or the 
shower-bath. In the rheumatic group of cases, much the 
same course of tonic treatment is generally applicable ; any 
special cardiac symptoms calling for appropriate remedies. 
In the reflex group, the rule of action is to remove the cause 
of reflex irritation. Cases with high temperature and a 



74 CHOREA. 

febrile condition indicate the presence of collateral disease, 
only indirectly associated with choreic movements, and call 
for treatment directed to the removal of the organic mischief. 
In several cases of very severe chorea, tartar-emetic has been 
found of great service ; and in many of moderate severity, 
bromide of potassium was apparently useful (Arlidge). 

Generally, therefore the indications for the treatment of 
chorea are — (i.) To remove, if possible, all morbid states of 
the body which may tend to aggravate the disease, such as 
constipation, anaemia, amenorrhcea, worms ; (2.) By well- 
regulated purgative medicines to subdue any cerebral con- 
gestion ; (3.) To sustain the strength and improve the vigor 
of the nervous system by tonic and stimulant medicines, by 
food, and by the cold bath. The particular tonic is not of 
much moment. Dr. Wood recommends the powder of the 
black snake root (cimicifuga, in doses of from half a drachm 
to a drachm, or from one to two fluid ounces of a decoction; 
or from one to two drachms of a saturated tincture should 
be given three or four times a day, and continued for several 
weeks, the dose being gradually increased till it produces 
headache, vertigo, or disordered vision. The sulphate of 
zinc has also had the credit ascribed to it of curing a large 
number of cases, beginning with a grain in the form of a 
pill, three times a day, and increasing the dose till it reaches 
seven or eight grains daily. The preparations of iron are 
also frequently resorted to with benefit. But Dr. Walshe 
did not find any of these remedies at all useful in the acute 
case he has described. Of all the remedies he tried, the 
" extract of cannabis Indica " was followed by the most 
satisfactory results. It exercised a sedative influence on the 
muscular action in a marked degree, and that immediately. 
The Indian hemp was given in doses of one-fourth of a 
grain of the extract thrice daily. The dose was subsequently 
increased to half a grain, and at the same time one-grain 
doses of nitrate of silver were administered, and a draught 
containing eight drops of dilute nitric acid. Nitrate 
of silver he found to have no mean influence in aiding 
the cure. Dr. Corrigan had also previously used Indian 
hemp with much success in chorea {Med. Times and Gazette, 
1845, p. 29 ; also Dublin Hosp Gazette}. 

The tincture of Calabar beans ( 3 i. to % i. of alcohol,) be- 
ginning with twenty minims three times a day, is also recom- 
mended by Dr. J. W. Ogle ; the dose to be increased by ten 
minims a dose, up to 3 i. The student is recommended to 



CHOREA, RHYTHMICAL HYSTERIC. 75 

consult a valuable paper " On the Uses of Indian Hemp in 
Nervous Diseases," by Professor Russell Reynolds, in Beale's 
Archives. 

Trousseau and Niemeyer consider narcotics to be of great 
value in the form of large doses of morphine; others are of 
opinion that narcotics are not well borne in chorea. 

Gentle applications of the galvanic current along the spine, 
the patient standing erect, have been successful in the hands 
cf Benedikt. The current should be just strong enough to 
be felt distinctly without pain. Chapman's ice-bags to the 
spine are also of use. 

Chloroform has been used with benefit to control the vio- 
lent movements. 

The best treatment is the improvement of diet, change of 
surroundings, and moral discipline. Hence it is that chil- 
dren with chorea improve so much in well administered hos- 
pitals, where the food is abundant and discipline well main- 
tained. But choreic patients must not be associated together, 
because the disease tends to be kept up apparently by imita- 
tion, especially amongst children. 

Of other classes of stimuli, camphor, in five-grain doses, 
has acquired much reputation, especially after the alvine dis- 
charges have become healthy by the action of purgatives. 
Many young women who attribute the attack to fright, fre- 
quently get well from the simple administration of the spirit 
of nitrous ether in one fluid drachm doses three times a day, 
combined with the officinal camphor mixture. The cata- 
logue of remedies which have been proposed is endless. In 
many instances, however, the above medicines may be con- 
tinued for weeks without any manifest improvement. In 
such cases the cold bath, or the cold shower bath, is an ex- 
cellent adjuvant; and, unless the patient is suffering from 
some structural disease, the case uniformly yields to this 
conjoined treatment; great care and attention being bestowed 
on the regulation of the diet, which should be light, nutri- 
tious, and easily digested. 

Chorea, Rhythmical Hysteric— Definition. — A chor- 
eiform affection under the influence of hysteria, and pre- 
ceded by it (Charcot). 

Treatment. — Professor Charcot recommends that prolonged 
and repeated ovarian compression might be maintained with 
benefit to such cases as occur in the female by means of some 
such instruments as are used for compression of large vessels 



76 COLIC COLIC, BILIARY. 

like the aorta. So also the application of ice bags to the 
ovarian region for half an hour at a time, repeated several 
times a day for several days, has had the effect of arresting 
the attacks, or of lessening their intensity. He prefers, how- 
ever, the inhalation of ether or of nitrite of amyl. Professor 
Trousseau has found cases of those forms of chorea to im- 
prove under the influence of oil of turpentine in capsules 
containing ten minims each, of which ten were taken daily 
for twelve to fifteen days a month; and to use warm baths of 
several hours' duration. 

Colic. — Definition. — A painful affection of some portion 
or the abdomen, caused by violent contraction of the mus- 
cular fibres of some portion of the intestinal canal. 

The Treatment is by opiates, chlorodyne stimulants, and 
purgative medicines. When the bowels are constipated, 
live grains of calomel, fifteen grains of jalap, and one 
grain of opium, should be administered immediately, and 
followed by — 

I£. Mist. Camphorae c. Magnesias Sulphat., 3j-J Tinct. 
Hyoscyami, m xv. to xx.; Tinct. Cardamomi, 3 j. To be 
repeated every five or six hours, until stools are obtained. 

In mild cases a scruple of rhubarb, or half an ounce of 
castor-oil, or other mild purgative, combined with a grain of 
opium, may be substituted for opium, calomel, and jalap. 
Some have doubted the propriety of administering opiates at 
the onset of the disease; but it is certain that a mild purga- 
tive, combined with a mild narcotic, will effect more than 
a drastic purgative without such combination. Opium in full 
doses (gr. i. to ii.) is more generally useful in colic than any 
other remedy. Enemata often give immediate relief. Exter- 
nally, the application of large bags filled wifnliot chamomile 
flowers, or of heated sand, or heated salt, or of the stomach- 
warmer filled with hot water, are useful. The warm bath, 
fomentations, or a large linseed or mustard poultice over the 
abdomen, are also highly useful auxiliaries. The diet should 
be sago and arrow-root, with a little brandy; and for some 
time after the patient has recovered it should be light, and 
perhaps limited to fish and puddings. 

Colic, Biliary. — Definition. — Concretions of certain bil- 
iary constituents in the biliary ducts, or accumulating gener- 
ally in the gall-bladder, as gall-stones, the passage of which 
through the duct into the duodenum gives rise to symptoms 
known as " gall-stone colic." 



COLIC, BILIARY. 77 

Treatment. — When the symptoms of gall-stone passing the 
duct are present, the curative indications are to facilitate its 
passage into the intestine, to relieve the intense pain which 
accompanies it, and to prevent that inflammation which the 
presence of an extraneous body of any magnitude is calcu- 
lated to produce in the duct. The first thing to be done is to 
calm the sufferings of the patient. Half a grain of solid 
opium, or a quarter of a grain of morphine, or twelve drops of 
laudanum, or the mistura camphoroe, 3 xj., conf. opii 3 ss. 
to 2>ij., c. sp. seth. nitr. 3 j., should be given every hour, or 
every two hours, till some relief is obtained, or till there is 
slight narcotism. Similar doses may be repeated every four 
or six hours, till the pain has ceased. If the vomiting be se- 
vere, and the remedies be rejected, the opiate may be given 
hypodermically, commencing with not more than one-fourth 
of a grain of the muriate of morphia in solution, or opium 
may be administered by enemata of laudanum. Careful in- 
halation of chloroform, till anaesthesia is produced, also gives 
great relief, and is a valuable remedy when paroxysms are 
most violent. It not only calms pain, but may lead to the ces- 
sation of the spasmodic contraction of the biliary passages, 
and thus favor the expulsion of the calculus (Murchison). 
Chloroform also, when given internally, appears to exercise 
some influence as a solvent of biliary concretions. Dr. J. 
Barclay relates an instance in which m ii. to m iii. of chloro- 
form, given three or four times a day, afforded great and im- 
mediate relief ( Brit. Med. Journal, 1870). Dr. Murchison 
has seen marked benefit from the extract of belladonna, given 
in half grain doses every two or three hours. The hydrate of 
chloral, as it produces extreme muscular relaxation, is also a 
likely remedy. Small pieces of ice in the mouth may relieve 
vomiting. Emetics or laxatives are not to be given during the 
attack. A warm bath should be immediately prepared, with 
a temperature of ioo° to no°, or as hot as the patient can 
bear it, and the immersion should continue till he is in some 
degree exhausted. The intention of the bath is to relax by 
means of heat the muscular fibre of the ducts, and thus re- 
lieve the pain and facilitate the passage of the gall-stone. The 
effect is generally so agreeable to the feelings of the patient 
that, on the recurrence of the pain, he may ask for a repeti- 
tion of it, and his wishes should be complied with. If a warm 
bath cannot be procured, fomentations, or a large linseed 
poultice, should be applied over the abdomen. Dry heat is 
always at hand, and hot flannels,, hot sand 3 or hot chamomile 



7^ COLIC, BILIARY. 

flowers afford some relief. Bleeding is not called for. The 
calculus having passed, and the patient being relieved, the se- 
cretions of the liver should be rendered more healthy. A 
course of neutral salts, or of the Cheltenham or Leamington 
waters, ought to be taken in this country. Under the use of 
the Karlsbad waters immense quantities of gall-stones are 
evacuated with proportionately little difficulty (Niemeyer). 
The same is true of other alkaline mineral Avaters, such as 
Vichy, Marienbad and Kissengen. 

The radical treatment of biliary calculi ought to be at- 
tempted during the intervals between the attacks of gall-stone 
colic, by — (i.) Solvents believed to act on the calculi. These 
are, — (a.) Alkaline solvents, which are to be preferred above 
all others. Under their influence the calculi seem to be 
really dissolved or broken up, so as to disappear without leav- 
ing any trace; or they are expelled entire in abundant bilious 
evacuations. This alkaline treatment comprises the fixed 
alkalies, soap-lye, salts of soda, carbonate of ammonia; but es- 
pecially the waters of Vichy, Vals, Karlsbad and Ems. These 
are used as drinks and as baths; and they must be employed 
perseveringly, at different periods, during several years in 
succession, (b.) Durande's remedy, which consists in the ad- 
ministration of half a drachm to a drachm every day, in the 
morning, of a mixture composed of fifteen grammes (7. e. y 
about 3 iii.) of sulphuric ether, and ten grammes (/. e., about 
3 ii.) of oil of turpentine, has enjoyed a reputation since 1790, 
as a solvent of biliary calculi. It has been extensively used 
and recommended by many Continental physicians. In this 
country Copland speaks favorably of it; but whatever virtue 
the remedy may possess as a solvent, it is probably due more 
to the ether than the turpentine, the former being a ready sol- 
vent of cholesterine (Waring). The dose is to be gradually 
increased till about a pound of this mixture has been taken. 
Its mode of action is not known; but where it has succeeded, 
the calculus has been expelled without being dissolved. It 
seems in some way efficient in promoting the expulsion of 
calculi, probably by its anti-spasmodic action, rather than 
acting as a solvent. Recently various substitutes have been 
proposed in place of Durande's remedy, and also variations 
from the original dose (Niemeyer). One is a popular remedy, 
a mixture of oil of turpentine, 2) ii. with 3 i- of spirits of sul- 
phuric ether, which has been prescribed in drop doses by 
Rademacher. (c.) Diet has a great influence upon the qual- 
ity of the bile. Fresh laxative vegetable food, grapes, fruits, 



CONSTIPATION. 



19 



and whey ought to constitute the staple articles of a regulated 
diet. All fat should be as much as possible excluded from 
food, and the plainest diet, in the form of roasted meats or 
boiled meats, with vegetables and farinaceous food, should 
be rigidly proportioned to the wants of the system. The 
drinks should be water or lemonade, and an avoidance of al- 
coholic or malted stimulants. (2.) Treatment which seeks to 
assuage pain. — With this end in view, Lutten prescribes 
opium in larger doses than those already mentioned — namely, 
two and one-third to three grains of solid opium at once; but 
he considers the hypodermic injection of solution of morphia 
as preferable ( " Nouveau Dictionaire de Medicine et de 
Chirurgie Practiques;" also, " Society Med. de Paris, 1866;" 
and " Sydenham Society's Biennial Retrospect for 1865-66"). 
The intense agony is more effectually relieved by large doses 
of opium than by any other remedy, particularly if it be com- 
bined with the use of the hot bath (Dr. Waring). Two grains 
of solid opium, or mxl. of the tincture of opium may be 
given, either by mouth or in the form of enema, to be re- 
peated in half an hour if the pain is not relieved. It may 
also be advantageously combined with a full dose of ether or 
chloroform, care being taken in case of over-dosing with the 
opiate. 

Large draughts of hot water, containing carbonate of soda 
in solution ( 3 i. to 3 ii. to twenty ounces of water) give 
more immediate relief than any other means (Dr. Prout). 
The first dose or two may be rejected; but the addition of a 
few drops of laudanum and steady perseverance in the rem- 
edy will eventually ensure its success (Murchison). No 
doubt can exist as to the efficacy of alkaline waters in re- 
moving the symptoms of gall-stones. It is certain that the 
salts of Vichy and Karlsbad waters relieve the symptoms of 
this affection, provided they are administered in hot water, 
and so as to represent nearly the strength of the natural 
springs. 

Constipation. — Definition. — A retention of faeces beyond 
the usual period, so that when they are passed it is with 
difficulty, and in a comparatively hard indurated state. 

Treatment. — There it no rule of health more important than 
that the bowels be kept regularly open. Enemata are of the 
first importance, and ought to be much more frequently em- 
ployed than they are as a habit. They may be simply a pint 
of warm water ioo° Fahr.; or the same quantity of warm 



8o CONSTIPATION. 

water, with half an ounce of common salt. The common 
soap enema (a strong solution of soap) is likewise a valuable 
remedy; and when the constipation is great, half a pint to a 
pint of castor-oil, neat, may be thrown up. For constipation 
in children and young persons nothing is so efficient as an en- 
ema of salt and water, repeated night and morning, or every 
night, or every other night only, according to the urgency of 
the symptoms. Large accumulations of scybala (stercoraceous 
tumors) seem visibly to melt away under their continuous in- 
fluence. These enemata ought afterwards to be followed by 
one or two drachms of sulphate of magnesia, one grain of 
quinia sulphatis, in aromatic sulphuric acid in an ounce of in- 
fusion of gentian, every morning till the bowels assume a 
healthy tone. A soap suppository, i.e., a piece of common 
yellow soap, shaped to an oval form, about half an inch thick 
at the middle part and an inch and a half long, introduced into 
the rectum, is also a useful stimulant to the action of a torpid 
rectum in children. When constipation is occasional and ac- 
cidental, any of the milder cathartics, in the absence of an 
enema, as the sulphates of soda or of magnesia, castor-oil, 
rhubarb, aloes, or the confectio sennas, or the pilulas colocyn- 
thidis comp., will in general open the bowels. In obstinate 
constipation, tartrate of antimony, to the extent of one-fourth 
of a grain, combined with a drachm of sulphate of magnesia 
every hour, may often bring fasces away after nausea super- 
venes. If, however, the constipation is habitual, the healthy 
habit of a daily evacuation is not easy to be re-established. The 
remedies, though often successful, yet occasionally fail. In 
cases of habitual constipation, the combination of tonic with 
laxative will often produce a more efficient action than a per- 
severance in the use of purgative medicines alone. Thus, 
two grains of the ferri sulphatis, or an ounce and a half of the 
infusion of gentian, combined with one or two drachms of 
sulphate of magnesia, given according to the urgency of the 
case, three times a day, or every six hours, will empty the 
bowel when the salt alone will fail. In old persons, a combi- 
nation of aromatics with the purgative, as in the decoctum 
aloes, is a more useful and effective remedy than the same or 
even a greater quantity of aloes alone. Aloes is a useful 
remedy when the colon seems specially at fault as a result of 
fever and debilitating diseases, or of sedentary habits and oc- 
cupations. The watery extract, combined with essential oil 
of ginger and jalapin; or with quinia, extract of nux vomica t 
ipecacuanha, are the most useful combinations. Where slow 



CONSTIPATION. 8l 

digestion, with a deficiency of mucous secretion prevails, the 
following is a formula for pills, of which one ought to be taken 
an hour before dinner (and before breakfast also) if required: 

3- Pulv. Ipecacuanha, gr. viii. to xii.; Ext. Aloe, gr. xii.; 
Sulphatis Ferri, gr. xviii. to xxiv. Misce, et divide in pil. xii. 

Or, the ipecacuanha may be omitted; or the aloes maybe 
combined only with some bitter extract, such as gentian. 
Such pills ought to be continued regularly till the occurrence 
of a " loose motion," after which one only, an hour before 
the principal meal, will be sufficient. 

Another formula for a pill of a similar nature is of use in 
habitual constipation, namely: 

3- Pil. Rhei. Co., vel Pil. Coloc. Co., vel Aloe, gr. ii. to iii.; 
Pul. Capsici, gr. i. To be taken with the food, and repeated 
daily as occasion may require (Pavy). 

Drastic purgatives ought never to be given. The diet 
ought to be especially attended to. More food, both sjlid 
and liquid, may require to be taken. When constipa- 
tion is obstinate, and has resisted the stronger purgative rem- 
edies, a full dose of opium sometimes seems to relax the 
spasm of the muscular coat of the bowels, on which the con- 
stipation may depend. Belladonna also may be given with 
advantage, in doses of -J- to -f of a grain every morning at 
rising, combined with the extract of gentian (Trousseau); 
or 10 minims of the tincture of belladonna maybe similarly 
taken. All medicines for the relief of constipation ought to 
given just before or with food; and are to be regarded as act- 
ing with the food in bringing about the result. Pills or 
draughts at bedtime are not so useful. In the constipation 
of children the sulphate of potass is recommended alike by 
Drs. Hiller and West. The following are useful formulae: 

5. Potas. Sulphatis, gr. xl. ; Syrup Rhei. 3 ss.; Aq. Carni 
Ad. § iii- ; Misce. Dose — A table-spoonful for a child six 
years of age (Hiller). 

I£. Potas. Sulphatis, gr. xii.; Infus. Rhei. 3 vss.; TinctAu- 
rant., 3 ss. ; Aq. Carni, 3 ii- ; Misce. Dose — A table-spoon- 
ful for a child three years of age (West). 

A severe case of colic with constipation, in the practice 
of Dr. Murchison recovered under the use of one-half grain 
of the extract of belladonna every four hours, with belladon- 
na ointment to the abdomen, a warm bath and castor oil 
enemeta {Lancet, Jan. 19, 187 1). When constipation arises 
from torpor of the colon, equal parts of compound gamboge 
pill and the compound colocynth pill is recommended by the 
6 



82 CONSTIPATION. 

late Dr. Symonds of Bristol (" Lib. of Medicine," Vol IV., p* 
139). The compound extract of colocynth, or compound 
colocynth pill variously combined with small doses of blue 
pill, or with ipecacuanha, or with podophyllin, or with 
nux vomica, is a safe and useful form for the relief 
of the bowels. Colchicum (tincture of the root) has been 
found of service in doses of ten drops several times 
daily (Chapman). When constipation does not yield to 
the simple treatment which has been mentioned, re- 
course must be had to more active remedies. Thus calo- 
mel, gr. v.; c. jalapae, gr. xv., is a dose which rarely fails 
to produce motions, and this if necessary, may be followed up 
four hours after, either by the neutral salts in divided doses, 
or by a black draught in one dose. If a stronger medicine 
than the above be necessary, elaterium is of greater power, 
and from -fa to i grain, combined with henbane, is sufficient 
to begin with, so as to avoid hypercatharsis. When the stools 
indicate a deficiency of bile, inspissated ox-gall has been 
recommended. It may be given in the following formula: 

1^. Fel. Bov. Purificat., 3 ii. ; 01. Carni, mx.; Magnes. 
Carb., q.s.; Misce. Divide in pil. xxxvi. Dose — Two to be 
taken daily (Waring); or, — 

$. Fel. Bov. Purificat., Pil. Asafcetid. Co., aa. gr. xxx.; 
Ex. Aloes, gr. xx.; Sapon. Dur. gr. x; Pulv. Ipecac, gr. 
viii. ; Misce. Divide in Pil. xxx. Dose — One or two may 
be taken daily before dinner (Copland). 

The resin of podophyllin, to the extent of -J- to J- of a 
grain combined with compound rhubarb pill, acts similarly 
to the combination of rhubarb pill with calomel. A length- 
ened period sometimes elapses before it operates. The 
tincture of benzoin, to the extent of gtt. xx. three times a 
day, will, it is said, keep the bowels active and regular (Hast- 
ings, Streetan). 

Sometimes the faecal matter accumulated in the colon is 
so large in quantity, and so hard and impacted, that manual 
assistance is necessary to relieve the patient. Women some- 
times suffer for years from constipated bowels; and a con- 
trary state of. the bowels may take place from the irritation 
of hardened faeces, when they are much harassed by purg- 
ing, existing more or less for many months. At length a 
violent tenesmus comes on, with a bearing down most intol- 
erable, much worse than a woman suffers in her confine- 
ments. On examining the rectum, a mass of hard matter 
mav be found, which cannot be broken to pieces without 



CONSUMPTION CONVULSIONS, INFANTILE. 83 

the aid of an instrument. This mass consists of a variety 
of undigested substances, which when broken down, may 
be washed away by injections, to the perfect relief of the 
patient. 

Dietetic Treatment. — Patients suffering from constipation 
should avoid port wine or brandy, and should eat freely of 
sub-acid fruits, drink more water, and in some cases eat 
more food of a kind likely to stimulate the colon, such as 
bran bread ; and oatmeal, in the form of cakes, or well- 
boiled porridge, should be eaten for breakfast. They should 
go daily at the same hour to stool ; for such is the periodical 
regularity of all the functions of the body, that they are more 
readily performed at accustomed hours than irregularly. 

Consumption — See Phthisis. 

Convulsions, Infantile. — Definition. — Convulsive seiz- 
ures, consisting of contraction of muscles by gradual but 
rapid shortening of the muscular fibres, causing such hard- 
ness and stiffness of the muscle or limb that it cannot be over- 
come. This period of tonic contraction is followed by clonic 
spasmodic phenomena, characterized by the occurrence of 
alternating movements of contraction and relaxation inde- 
pendent of the will, which is as powerless to suspend or mod- 
erate them as to excite them (Trousseau.) 

Treatment. — Of all the causes mentioned in connection 
with convulsions, none are so common or universal as indi- 
gestion. Hence the quantity and quality of the food and 
condition of the evacuations, by vomiting or by stool, ought 
to be inquired into at the first. If some unwholesome diet 
has been given, a good purgative of calomel, mixed with pow- 
dered sugar, should be put on the back of the child's tongue. 
If indigestion is traced as the source of the fits in an infant 
or young child, a few drops of aromatic spirit of ammonia, or 
the same quantity of ether, may be given in a teaspoonful of 
water; or a drop or two of anise oil, rubbed up with sugar, 
may be given from time to time, by laying the powdered 
sugar so saturated on the tongue of the child. It is in such 
cases that mere flatus in the bowels may cause a fit in a pre- 
disposed child. The belly will be found tumid, when gentle 
friction over the abdomen (following the direction of the co- 
lon), combined with the warm bath and those soothing aro- 
matics, will give relief. 

The clothing must be loosened completely, so as to admit 
air freely, and anti-spmasmodics, such as ether alone, or com- 



84 CONVULSIONS, INFANTILE. 

bined with musk or belladonna, may be given, till the pro- 
gress, duration, seat, or probable cause of the convulsions 
may be ascertained. An emetic, a purgative enema, a search- 
ing purgative, such as calomel, combined with jalup or rhu- 
barb, may be indicated-; or the removal of a pin in the dress, 
which had been long pricking the skin, or too tight a dress, 
may, on removal or rectification, cause the convulsions to 
cease. 

In all cases, however, when a child we have never seen be- 
fore is found in a fit, it is best to order a warm bath to be 
prepared, and to have the room freely ventilated. The next 
points to inquire into are the condition of the pulse and of 
the child's head as to form and completion of its bones. 
" Pass one hand quietly and carefully over the child's head 
while the pulse is felt with the other. Fulness or weakness 
of the pulse will be a guide to diagnosis; so also if the head 
be hot or cold, if the anterior fontanelle be tense and pro- 
truding, or sunk and retracted, and if the face be flushed or 
pale " (Ellis, Diseases of Children). 

When the child is completely stripped of its clothing, it 
should be observed if the legs are drawn upwards to its belly, 
and if so, and the head be hot, and the fontanelle prominent; 
there is congestion of the head, which may either ue the 
cause or the consequence of the fits. In any case the child 
should be placed first with its feet in the bath, in which a 
handful of mustard may be mixed (two ounces of mustard to 
four gallons of water). At the same time vinegar and water, 
or spirits and water lotion, may be applied to the child's head; 
while hot flannel cloths wrung out of the hot mustard and 
water bath (with more mustard sprinkled on the surface of 
the flannel) should envelop each leg and foot. If the head 
be cold or the fontanelle depressed, the entire body of the 
child should be immersed in the mustard and water bath 
(temperature about 98 Fahr.); and friction employed over 
the whole skin. A little sal-volatile map be held to the nose, 
and a few drops of brandy in a teaspoonful of water may be 
used to moisten the lips. It is possible the child may be in 
a state of faint or syncope, and not in a fit. 

During these proceedings it is important to find out the 
previous medical history of the child, as to, — (1.) Which of 
the acute specific diseases it may have had. (2.) State of 
dentition, and also condition of gums to be determined, by 
passing the finger along them. (3.) What the child may have 
been eating recently. (4.) The previous existence of diar- 



CONVULStOS, INFANTILE. 85 

rhcea. (5.) The previous occurrence of carpopedal twitch- 
ings, or drawing in of the hands and feet, with general irri- 
tability. If this latter condition is found to have existed, 
and if the fontanelle be prominent, there is some abnormal 
condition" of the nervous system. A calomel purgative may 
be required, or leeches, or a rubefacient behind the ear or 
over the vertex. With headache, vomiting, and some fever- 
ishness, a pulse of 130 would rather point to stomachal dis- 
turbance; whereas with a slow pulse (say at 40), these symp- 
toms would rather indicate an early manifestation of tuber- 
cular meningitis, where bromide of potassium or ammonium 
may be required after suitable purgation. If recently con- 
valescent from scarlatina, and there be albuminuria or an- 
asarca, a hydragogue cathartic may be required, in the form 
of twenty grains of compound jalap powder with a grain of 
scammony, to a child five years of age, repeated every two 
or three hours till the desired result is produced. It may be 
necessary at the same time to dry-cup the loins. If convul- 
sions come on daring hooping-cough, apply ice or cold to the 
head, with free purgation, and use a sedative cough mixture 
(Ellis, 1. c, p. 

A clyster of one part vinegar and three parts water, the ap- 
plication of cold compresses to the head, or of leeches be- 
hind the ear, if the convulsions do not subside, are remedies 
advocated by Niemeyer. 

If symptoms denote stupor, cold affusion should be pre- 
scribed; if, on the other hand, they denote "some collapse, 
wine, camphor, musk, and other stimulants must be used. 

If dentition is causing the convulsions, the dense tissue of 
the gums over the tooth ought to be relieved by lancing it, or 
cutting it across over the crown of the tooth. 

Dr. Tanner advises the administration of bromide of po- 
tassium as a medicine from which more may be hoped for 
than from any other. If there be inability to swallow, it 
ought to be given in enemata of beef-tea. 

Where great restlessness prevails, dilute hydrocyanic acid, 
with tincture of hyoscyamus, may be given. 

Compression of the carotid arteries and chloroform inhal- 
ation, or a mixture of ether and chloroform, are only to be 
had recourse to in cases of prolonged duration, depending on 
such irritation as that of dentition. Anaesthesia thus induced 
is of great value. 

Trousseau is strongly opposed to blisters and general " re- 
vulsions to the skin," except in some cases of "inward fits " 



86 CONVULSIONS, PUERPERAL. 

involving the diaphragm or the heart. In such cases the ac- 
cion of the remedy, as ammonia, must be immediate. 

Convulsions, Puerperal — Definition. — An acute affec- 
tion of the nervous system, characterized by loss of conscious- 
ness and sensibility, by tonic and by clonic spasms. It occurs 
only as an accessory phenomenon of another disease (gener- 
ally Bright's, in an acute form) which, under certain circum- 
stances, spreading its toxemic effects on the nutrition of the 
brain and the whole nervous system, gives rise to convul- 
sions. The blood-poisoning is generally to be referred to 
anaemia, or to the products of the changes in urea which are 
retained in the blood, or to the retention of other excremen- 
titious constituents of the urine (Braun). 

Treatment. — If oedema with albuminuria and tube casts 
in the urine are observed during the course of pregnancy, 
the morbid condition may be kept in check, and the exten- 
sion of the disease may be prevented by hygienic manage- 
ment and medicinal remedies. The watery and otherwise 
deteriorated condition of the blood is to be ameliorated by a 
liberal and properly assorted dietary, and by ferruginous 
tonics ; and a good general effect is often produced by the 
use of tepid and vapor baths (Caxeaux, Leishman). It has 
also been suggested by Frierichs that tartaric acid, benzoic 
acid, or lemon juice should be regularly given, with the idea 
•that these will prevent decomposition of the urea in the blood, 
or neutralize the carbonate of ammonia already formed. 
The functions of the bowels must be regulated with care. 
Purgation as a prophylactic must be resorted to with cau- 
tion. Compound jalap powder, in electuary, with or with- 
out guaiacum, are the most efficient and least depressing 
medicines for this purpose. The quantity and the micoscopic 
appearances of the urine furnish the best indications as to 
the necessity for the use of diuretics. When exudation has 
taken place into the Malpighian capsules and the tubes, it is 
desirable to clear them of the obstruction, and prevent its 
reformation. The copious use of diluents may effect this 
desirable result. But if the secretion of urine be scanty, 
and uraemic intoxication threaten to come on, the secretion 
of urine must be increased. The acids already named, and 
the mineral waters of Seltzer and Vichy, are the remedies 
best adapted for this purpose (Braun, Leishman). I find also 
frequently repeated small doses of bicarbonate of soda com- 
bined with spirits o ( nitrous ether in large quantities of cold 



COUP DE SOLEIL. CRETINISM. Sj 

barley water, an efficient diuretic in such circumstances. 
Pills of tannin and extract of aloes may be used for restor- 
ing the normal tone. Labor should only be provoked when 
the symptoms are such that the life of the mother is in dan- 
ger (Braun, Leishman). 

In the treatment of the fits, procedure is different accord- 
ing as they happen during pregnancy, during labour, or after 
delivery. During the paroxysm, the indications are the same 
in all cases. As to blood-letting, there are certain cases in 
which the constitution and temperament of the woman, the 
violence of the attack, combined with evidence of vascular 
tension within the cranium (such as throbbing carotids, 
marked suffusion of the eyes and face), warrant us in believ- 
ing that by venesection we give the patient the best chance 
of recovery, or in such cases leeches may be freely applied 
to the temples and ice to the head. In cases which do not 
present these indications for blood-letting, the administra- 
tion of chloroform, ether, and other anaesthetic agents, pro- 
duces a beneficial effect. Symptoms which suggest the ap- 
proach of a first seizure, or a repeated paroxysm, are a suffi- 
cient warrant to adopt this method of treatment. It is the 
premonitory symptoms which must be held in control by 
anaesthetics, — their use is too late when the respiration is 
impeded. Chloral hydrate has also been strongly recom- 
mended, and it has this further advantage, that " when it is 
pushed further it produces an anaesthetic effect, under the 
influence of which a woman may be delivered without expe- 
riencing the slightest suffering" (Leishman). In ordinary se- 
dative doses — not more than thirty grains — its 'effect is safe, 
and in most cases efficacious ; but if larger and repeated 
doses are required, its cumulative action is such that very 
alarming symptoms are occasionally produced, and death 
has even been the result of what might be considered quite 
an ordinary dose. Four drachms have been administered by 
enema within three days. Sponging with warm water, or te- 
pid vinegar and water, has been found useful. Opium is not 
to be administered in cases where albuminuria is present. 
(For obstetric details, see Leishman's " System of Midwif- 
ery," 3d Edition, p. 776.) 

Coup de Soleil — See Sunstroke. 

Cretinism! — Definition. — A condition of imperfect devel- 
opment and deformity of the whole body, especially of the 
head. It is endemic in the valleys of certain mountainous 



88 croup. 

districts, and is attended by feebleness or absence of the 
mental faculties, and sometimes of the special senses. It 
is often associated with goitre. 

Treatment. — The indications of treatment are those which 
suggest improvement in all hygienic measures for the pre- 
vention of the disease. Dr. Gubbenbuhl, of Zurich, was the 
first to recognize the fact that the mental state of cretins 
could be improved by improving the growth and condition of 
the body. In 1842 he succeeded in buying the mountain of 
Abendberg, which incloses the plain of Interlaken, and there 
he established an hospital for these unfortunate children. 
The infant cretins, removed from the low close valleys (in 
which the malady too often finds the circumstances most 
congenial for its development), are there fed and trained in 
" the free, dry, cool, and bracing air of the open but sheltered 
and sunny slopes of the Abendberg." Once established, 
the condition of the cretin can only be ameliorated by insti- 
tutions similar to those founded by Dr. Guggenbuhl. The 
condition is beyond medicinal remedies. 

Croup. — Definition. — A "non-infectious inflammation of 
the mucous membrane of the trachea, occurring in children, 
differing from other inflammations in like tissue in the pres- 
ence of plastic exudation " (Barclay) ; or it is a disease ac- 
companied by the exudation of a fibrino-albuminous material 
which rapidly coagulates upon the mucous membrane of the 
epiglottis, glottis, larynx, or trachea, and sometimes over all 
of these parts ; indicated by accelerated, difficult, wheezing, 
or shrill respiration ; short, dry, constant, barking cough, 
voice altered by hoarseness, with spasm of the interior lar- 
yngeal muscles, and pain and constriction above the sternum, 
frequently followed, towards the close of the disease, by ex- 
pectoration of a membranous albuminous substance, or even 
of a cylindrical cast of some portion of the breathing tube. 
The disease occurs in children, and may terminate fatally, 
either in suffocation or exhaustion of the vital powers. 

Treatment. — Every case of croup demands the most active, 
efficient, and energetic treatment. Great and diametrical as 
are the pathological differences of croup and diphtheria, the 
treatment most effectual in either is not the less decided and 
opposite. While calomel in purgative doses, tartar emetic, 
and blood-letting may each and all of them be demanded in 
croup, these agents would be most baneful in diphtheria, 
which is most successfully combated by the administration of 
the mineral acids (especially the nitric and hydrochloric), 



CROUP. 89 

chlorate of potash, quinine, and iron (See Diphtheria). Bleed- 
ing, especially local, should be employed in most cases to a 
considerable extent (an ounce of blood for every year of 
age) ; and two to twelve leeches, according to the age of the 
patient, should be applied over the trachea and larynx. The 
bleeding should be encouraged by the application of a lin- 
seed poultice to the throat. This first bleeding often gives 
great relief, and sometimes averts the danger. If not, the 
leeching after a few hours may be repeated. As soon as 
some relief is obtained, a blister should be applied along the 
lateral aspect of the neck on each side, and not over the tra- 
chea. The blistered surface should be dressed with mercu- 
rial ointment. Many practitioners prescribe emetics also ; 
first, because their emetic effects, and the large evacuations 
they produce, favor the resolution of the inflammation ; and 
second, because the effort of vomiting may be the means of 
detaching and of expelling the false membrane, should it 
have formed. So soon as croupy cough and dyspnoea occur, 
an emetic of ipecacuanha with tartar emetic ought at once to 
be given in doses suited to age. Four to six grains of ipeca- 
cuanha, combined with a quarter or a third of a grain of tar- 
tar emetic, will be sufficient for a child of two or three years 
of age. The action of the emetic may be aided by a warm 
bath of 98 to ioo° Fahr. If it becomes obvious that the 
exudation has assumed the form of a membrane, especially if 
indicated by a diphtheritic coating over the fauces, a solution 
of the nitrate of silver, varying in strength from forty to one 
hundred and twenty grains to the fluid ounce of distilled 
water, should be applied to as much of the fauces and larynx 
as can be reached. A sponge on the end of a piece of whale- 
bone should be loaded with the weaker solution, and squeezed 
against the rima glottidis two or three times a day. Bleeding 
has no effect in removing or modifying the false membrane ; 
but the system must be brought as speedily as possible under 
the influence of mercury. Two, three, or four grainy of calo- 
mel, with two or three grains of James's powder, may be 
given at short intervals every two or three hours ; and a dose 
of castor-oil occasionally, till the full effect of the calomel as 
a purgative is obtained. Green fsecal stools, like chopped 
spinach, are characteristic of this result. Mercury appears a 
powerful resource in these cases ; and, introduced either in- 
ternally or by inunction, so as to affect the mouth, but with- 
out inducing salivation, uniformly gives relief as soon as its 
constitutional action is established. 



90 CROUP. 

Bleeding, blistering, and mercury, although the rule of 
treatment in idiopathic infantine croup, are, for the most 
part, entirely inefficient in those cases in which the affection 
begins in the fauces, as in the case of many epidemics^ espe- 
cially after scarlatina, which are really cases of diphtheria. 
Expectorant medicines should be given with the mercurials, 
and be continued after them. Ipecacuanha and senega are 
most efficient. 

Tracheotomy, when not too long delayed, has saved many 
a life in croup, while it has proved utterly abortive in diph- 
theria, which is beyond the reach of any such topical 
remedy. M. Trousseau has saved one-third of his patients 
by its means ; and of twenty cases Bretonneau saved six. 
Perhaps the experience of the profession generally is some- 
what discordant on this point at present. Those who oper- 
ate early save some of their patients, while those who wait 
till a case is advanced, and beyond medical treatment, before 
they resort to this measure, for the most part lose all their 
patients. The evidence, however, is daily accumulating 
which shows that tracheotomy ought to be resorted to much 
oftener as a remedy for croup than it has hitherto been, and 
that at a much earlier period in the disease, — not as a last 
resource, when death from asphyxia appears imminent, and 
after treatment of the most depressing kind. That this is 
the secret of success in France and in this country, is shown 
by the experience of able physicians and good surgeons, of 
whom the names of M. Trousseau, the late Mr. Jones, of 
Jersey, Mr. Henry Smith and Dr. Fuller, of London, the late 
Dr. Cruickshank, of Dalmellington, in Scotland, and Mr. 
Spence, Professor of Surgery in the University of Edinburgh, 
Dr. George Buchanan, in Glasgow, and Professor Roser, of 
Tubingen, may be stated as authorities by experience. In 
country districts the performance of tracheotomy in a case 
of croup is almost imperatively called for in the majority of 
cases, if some symptoms of amelioration do not follow the 
steady use of bleeding, emetics, the warm bath, and calomel 
purgation, pursued for twelve or sixteen hours. I know 
from personal knowledge in a wild country district of Scot- 
land, where croup was very common and fatal, that the late 
Dr. Cruickshank saved eight out of eleven cases during two 
years. A valuable paper by Mr. Smith, in The Medical 
Times and Gazette, January 26, 1856; another by the late 
Mr. Jones, of Jersey, in the 8th November of that year ; 
and, lastly, a paper by Dr. Conway Evans, in the The Edi?i- 



CROUP. 91 

burgh Medical Journal for January and May, 1S60, go to 
support the same conclusion, — namely that an earlier intro- 
duction of air, by the operation of tracheotomy, for croup, 
would not only give a larger percentage of recoveries in this 
country, but would place the operation in the same favorable 
light in which it is now regarded in Paris and other parts of 
France. Tracheotomy in croup is undoubtedly gaining 
ground ; and it cannot be denied that children perish, in the 
first instance, almost always from suffocation. Tracheotomy 
is therefore indicated in croup as soon as there are urgent 
symptoms of obstruction of the glottis. When the respiration 
is so impeded that the demand for oxygen is only satisfied by 
difficult forced respirations, dreadful anguish is depicted on 
the reddened countenance covered with sweat ; there is 
extreme restlessness ; the patient tosses from side to side, 
gets out of bed one minute and into it the next, clutching 
spasmodically at those around him, as if seeking everywhere 
for help. This is the proper period for the operation of 
tracheotomy in croup, — the time when success may be 
expected (Roser). Should the operation be longer delayed, 
symptoms of asyhyxia appear, overloading of the blood with 
carbon ensues, the face suddenly becomes blue, with fixed 
and staring eyes, convulsive exertions are made, and anxious 
struggles for breath follow the stage of suffocative agony. In 
some cases the symptoms of asphyxia come on more slowly, 
and are apt to make considerable progress before the danger 
is fully appreciated. This insidious form of asphyxia is 
denoted by symptoms of great weariness and weakness, rest- 
lessness, oppression, anxious startings out of short slumbers, 
loss of consciousness and of feeling, approaching stupor, the 
face pale, and tending to become cedematous. If tracheotomy 
is delayed till these symptoms become expressed, it may still 
enable the child to breathe more freely, and thereby may 
promote the chances of recovery ; but the child has usually 
no longer power to resist the advancing bronchitis. The causes 
of death after the operation are mainly pneumonia, bronchitis, 
or the severity of the constitutional febrile state (Syden. 
Society Year-Book, 1863, p. 278). In diphtheria the fatal 
result depends on a cause acting generally on the system, 
which ultimately destroys the patient, and which tracheo- 
tomy will not prevent. Age influences success to a consider- 
able extent. Under two years of age few cases recover ; but 
between the ages of six and twelve nearly one-half are saved 
(Conway Evans). 



Q2 CROUP, SPASMODIC CYSTITIS. 

Croup, Spasmodic — See Laryngismus Stridulus. 

Cyanosis. — Definition. — A peculiar blue condition of the 
skin, symptomatic of various malformations or derangements 
of the heart and great vessels, so that a small portion only 
of the blood is subjected to aeration in the lungs. 

Treatment must depend upon the nature of the lesion or 
disease which gives rise to the cyanosis. The inhalation of 
oxygen gas has given relief in some cases. 

Cynancke Tonsillaris — See Quinsy. 

Cystitis. — Definition. — Inflammation of the urinary Dlad- 
der. 

Treatment. — The causes must, if possible, be removed. 
Purging, together with opiates, diluents, and the warm bath, 
are the best means of curing the acute affections. Chronic 
inflammation of the bladder, and especially catarrh, is very 
difficult of cure, and often our best directed efforts are un- 
successful. Opium is the remedy of the greatest value, 
especially aided by hot hip-baths, hot fomentations over the 
abdomen, and linseed-meal poultices, with or without mus- 
tard or turpentine, over the hypogastric region. Supposi- 
tories of morphia are of great use, containing half a grain to 
a grain of opium ; but if the pain be very great, much larger 
doses may be given — as much as two to four grains of opium, 
with ten to fifteen grains of extract of hyoscyamus, in a sup- 
pository, at the hour of sleep. Alkaline and demulcent 
drinks should be at the same time given. The state of the 
urine is one of the surest guides in our attempts to cure the 
patient. If the urine be acid, the best medicines are the 
neutral salts or the pure alkalies, with opiates ; while, if the 
urine be alkaline, or greatly loaded with mucus, the mineral 
acids are of the most service, combined with an opiate. 
Thus the infusio rosae c. acidi sulph. dilut. mij. to v., c. mag- 
nesias sulphatis, 3 j., c. tinct opii, miij. to v., every sixth 
hour, is one of our best and most useful remedies. Tonics 
often succeed when other remedies fail, and of these salicine 
is one of the best. It may be given in doses of ten grains 
every six hours. It must be admitted that much difference 
of opinion prevails as to the best tonic remedy, some pre- 
ferring uva ursi, others pareira, others the turpentines, as the 
Canadian balsam, and others again the infusio diosmae. In 
chronic catarrh, when the discharge is copious, the decoction 
of uva ursi, in doses of not less than half a pint daily, is very 
soothing. It is of most advantage in cases of irritability 



DELIRIUM TREMENS— DENGUE. 93 

rather than of inflammation, prescribed in large doses, from 
one to two drachms of the extract daily, or from eight to 
sixteen ounces of the infusion as a drink, made as follows: — 
3. Fol. uvae ursi, | i. ; Aq. Fervid., f 3 xviii. Macerate 
for two hours, and boil down to 16 ounces, and strain (Sir 
Benjamin Brodie). 

Delirium Tremens — See Alcoholism. 

Dengue. — Definition. — A specific continued fever or feb- 
ricula, eminently contagious, and having an incubation- 
period of a few hours to one to seven days (Charles), charac- 
terized by frontal headache, by severe pains in the limbs and 
trunk, and sometimes by an eruption, resembling that of 
measles, over the body. The disease occurs chiefly in the 
West Indies. 

Treatment. — Time is an essential element in the treatment- 
Emetics and purgation may be given if indicated. Calumba 
and rhubarb with soda form a useful alterative medicine. 
Emetics of tartrate of antimony and ipecacuanha bring away 
large quantities of bile, relieving the pains of the head and 
limbs almost immediately ; and the eliminative action ought 
afterwards to be maintained by sulphate of magnesia and 
tartar emetic. It may be necessary to repeat the emetic 
till bile is discharged from the stomach. Dr. Charles' ex- 
perience leads him to say that most patients get on better 
without any emetic, which ought only to be given where the 
tongue is much loaded and where there is gastric derange- 
ment and nausea. Colchicum, sweet spirits of nitre, nitrate 
of potash, and antimony, in proportions sufficient for dia- 
phoresis, given every two hours, with an additional efferves- 
cing draught, exercise a beneficial influence on the pains. 
After the acute symptoms subside, forty to sixty drops of the 
wine of colchicum, with twenty-five drops of laudanum, to 
which thirty drops of antimonial wine may be added, always 
ensure a good night's rest. Dr. Christie treated his cases by 
purgation during the first day, and in other respects as he 
would a case of malarious fever, by five-grain doses of 
quinine. When the febrile symptoms subsided iodide of po- 
tassium, in four-grain doses, was given, and continued dur- 
ing the remission, and for a few days after desquamation of 
the cuticle had taken place. Dr. Charles considers purga- 
tion ought not to be used in dengue, as it adds to the tor- 
tures of the disease and is too lowering. He considers bella- 



94 DIABETES MELLITUS. 

donna a sovereign remedy in the pains of dengue, and pre- 
scribes it thus, — To one drachm of the tincture of belladonna 
he adds five drachms of orange syrup, and directs a sixth 
part to be taken every hour by an adult till the third dose is 
given, which may give so marked relief that no more need be 
taken. Less than three such doses seldom is sufficient, and in 
very severe pains two or three doses may be given in one. 
One-third to half grain doses of the extract, repeated twice 
or thrice in the twenty-four hours, will also generally suffice. 
Atropia may be used hypodermically in solution of one grain 
of the sulphate to an ounce of water ; of which 8 minims are 
sufficient for most cases, while 10 minims (containing ■£$ of 
a grain) is a full dose for a powerful, well-developed adult. 
Such a dose must not be exceeded in any case ; and atropia 
is only to be used thus to afford rapid relief when pain is very 
intense, and has lasted for some time. Five minims of the 
solution is enough for a child of twelve years (containing -fa 
of a grain). Cold water in the form of cold sponging has 
been found of great service in the hyperpyrexia of dengue , 
and the cold bath is worthy of consideration. 

Diabetes Mellitus. — Definition. — A constitutional dis- 
ease produced through errors in the processes of assimila- 
tion either in the stomach, in the solid organs, or in the 
blood, and cha-acterized especially by an excessive thirst, an 
excessive discharge of urine, more or less constantly saccha- 
rine, to an extent of over 10 grammes (154 grains) of sugar 
per litre (35-3 ounces) of urine (Laseque), and associated 
with progressive emaciation of the body, often ending sud- 
denly by coma from acetonemia or by convulsions. 

Treatment. — There are few diseases in which the treat- 
ment has been more varied than in diabetes mellitus. Every 
conceivable medicine has been given, but exact determina- 
tions of their effects on the sugar have rarely been made. 
The emaciated state of the patient presents an insurmount- 
able obstacle to bleeding. Nevertheless, this mode of treat- 
ment has often been practised : but the pathology of diabe- 
tes, as given in the text, does not sanction general blood- 
letting as a mode of cure. 

Mercury alike with lead, antimony, zinc, silver, and cop- 
per, are indifferent as to their influence on the formation of 
sugar (Parkes). Opium has been given to the extent of 100 
grains in the twenty-four hours ; but with an equal want of 
success, although it does seem to lessen the sugar, probably 
by lessening the appetite and hindering the taking of food 



• DIABETES MELLITUS. 95 

(Parkes). Nevertheless opium and its preparations, especi- 
ally codeia, have among all known remedies the most decis- 
ive influence on the excretion of sugar ; but the duration of 
the action is only exceptionally an enduring one (Seegen). 
The whole materia medica has been exhausted in search of 
a remedy for this disease. The metals, the fixed and the 
volatile alkalies, the vegetable and mineral acids, the astrin- 
gents, purgatives, tonics, diaphoretics, and diuretics, have 
each in their turn been administered, and each has perhaps 
afforded some relief ; but the disease has proceeded, and 
finally, it may be said, nearly every patient dies whose treat- 
ment is left entirely to drugs. Dr. Prout, who considered 
diabetes merely as a form of dyspepsia, conceived that each 
case requires a special treatment. In the early stages of the 
disease some have found great benefit from the tincture of 
the muriate of iron, now called the tincture of the perchlo- 
ride of iron. Dr. Camplin speaks of the citrate of ammonia 
in the effervescent form, generally combined with the citrate 
of iron as more useful than any other medicine ; while bit- 
ters and alkaline remedies did him great service at one 
period of his attack. Amongst remedies, alkalies, as recom- 
mended by Miahle and Contour, and mineral waters have 
proved themselves the best. The use of Carlsbad water 
has always a favorable influence, the amount and duration 
of the influence varying with the severity of the disease (See- 
gen). The quantity of sugar in diabetes decreases under 
the use of alkalies, and at the same time the patient is better 
nourished. This action of the alkalies depends probably 
upon an increased oxidation of the hydrates of carbon in the 
blood of the non-muscular tissues, by which partly the want 
of oxygen in the muscles may be compensated. If the un- 
known cause cannot be removed, in consequence of which 
the muscles cease to decompose sugar, there are no re- 
medies by which we might decompose the sugar in a diabetic 
diseased organism. But we may partly supply, in the blood 
of diabetic patients, what is wanted. Besides alkalies, we 
may use paralactic acid ; and as glycerine acts in a similar 
manner as paralactic acid, — u e., is easily consumed in the 
blood — it deserves to be taken into consideration in such 
cases. It has been given with benefit to the extent of six 
to eight drachms daily ; and its administration should be 
continued uninterruptedly for at least one month. In place 
of paralactic acid, there may be used lactic acid, as it is also 
consumed in the blood. 



g6 DIABETES MELLITUS. 

Opium, combined with ipecacuanha, is eminently useful 
as a sedative, especially in the form of Dover's powder ; 
while exercise, warm clothing, friction of the surface, hot 
bathing, and diaphoretics, improve the cutaneous functions. 
The functions of the skin must always be inquired into, and 
must be kept active. The nitro-muriatic acid baths, and the 
internal administration of the acid, might also be employed 
with some prospect of benefit in cases requiring acid tonics. 
This is more generally the case in the young, and in the 
early stages of the disease, in which the tincture of the per- 
chloride of iron is also of service, prescribed in the infusion 
of quassia or of calumba. But each case requires to be 
made a special study, considering that many, or at least sev- 
eral, organs are concerned in the disorded working of the 
system (Prout, Camplin). The mistura ferri composita is 
another of the iron preparations which has been found of 
service. With the view of diminishing the morbid ferment 
in the stomach, Drs. W. Ebstein and Julius Muller, of Bres- 
lau, have prescribed carbolic acid with advantage. It was 
given dissolved in peppermint water (the strength being i 
gramme to 300 grammes), about six to seven tablespoonfuls 
of this solution being taken in a day. It has also been 
found" of use in the treatment of the acetonemia (B. poster). 
One to three grains may be given in glycerine or in a pill, 
twice or thrice a day. Valerian has also been found of use 
in diminishing the excretion of urea (Bouchardat), and so 
lessening thirst. He gives it in repeated small doses, and 
gradually increases the amount taken until he has, in some 
cases, reached a dose of 30 grammes (450 grains) in twenty- 
four hours {Med. Times and Gazette, Vol I., p. 568). With 
regard to the acetonaemia, transfusion has failed in this 
country and abroad. So also has the injection of a saline 
solution into the blood, as practised by Drs. E. H. Fagge 
and F. Taylor, of Guy's Hospital {GuysHosft. Report, XIX., 
p. 173 and 521). Salicylic acid and its salts are also worthy 
of trial, so is thymol (B. Foster, Burdon Sanderson). In 
the severe form of cardialgia, I have found great benefit to 
result from the use of Seller's Bismuth Mixture, prepared by 
Messrs. Mackay, Sellers & Co., 1 and 2 Bouverie street, Lon- 
don, in half-drachm doses, mixed with water, three or four 
times a day. Dr. Garrod writes favorably of the sulphide of 
ammonium as useful, in so far as it controls the morbid appe- 
tite ; and Dr. S. Ringer finds sulphide of calcium of use. 
In the affections of the genitals in the female, I have found 



DIABETES MELLITUS. 97 

the intense pruritus to be best relieved by bathing in solution 
of Condy's fluid (permanganate of potash) in copious and 
frequent ablutions, or by vaginal injections without soap. 
Winckel has found a solution of one part of salicylic acid in 
300 of water ; but glycerole of lead, zinc ointment, white 
precipitate ointment, glycerine and tannin, sitz baths with 
bran, carbolic acid solution (i grain to 4 ounces of water as 
a vaginal injection, or 5 grains to the ounce as a lotion), 
may each in their turn be of use in relieving these 
most distressing of the symptoms and complications of 
diabetes. 

The little benefit derived from medicine induced Dr. 
Rollo to try the effects of an entirely azoted or animal diet ; 
and now it is found that the regulation of the diet is of the 
first and primest importance in the treatment of diabetes. 
A full and generous diet is unquestionably useful ; but the 
patient soon gets disgusted with mutton or beef, or both, for 
breakfast, dinner, and supper : he consequently nauseates a 
meat diet, and abandons it altogether. A diet of salt fish 
has been attempted, but the patient in a short time so 
loathes it that it has to be given up. A mixed diet, therefore, if 
contraindicated by some theories, is at least the best to 
adopt in practice, if duly regulated and aided by other 
means. It will be evident, however, that those vegetables 
which contain a large quantity of saccharine matter should 
be avoided, as potatoes, grapes, or other very ripe fruit, and 
a fortiori, sugar itself. 

" However surely an exclusive animal diet may lessen or 
entirely remove, the sugar in the urine of a diabetic patient, it 
is certain that it cannot long be tolerated." " In this opinion 
Niemeyer, Trousseau, and many other physicians now con- 
cur: "Under its use the appetite fails, and a loathing of all 
food soon happens. The necessity of a mixed diet for man 
is as necessary for him when suffering from diabetes as in a 
state of health. In this disease the nervous system is un- 
doubtedly implicated, and a rigid adherence to animal food 
alone, were it practicable, would soon be followed by an 
aggravation of the nervous troubles. There is, from the very 
beginning, and throughout the course of the disorder, a 
strong tendency to devitalization, and this too must be 
guarded against. Fortunately the sugar in the urine may 
be kept down, and at the same time the general strength of 
the system maintained, by a properly adjusted diet of mixed 
food. Along, then, with the carnivorous dietary, whose im- 



98 DIABETES MELLITUS. 

portance is not to be undervalued, certain vegetables may be 
permitted, not only with impunity, but with advantage. 
These are, cabbage, cauliflowers, onions, spinach, water- 
cress, sorrel, endive, lettuce, &c. Trousseau has found no 
ill consequences from eating acid fruits, as strawberries, 
gooseberries, cherries, and he has allowed apples, pears and 
grapes. He even suffers his diabetic patients to eat a small 
quantity of bread, if they greatly crave for it. As he re- 
marks, there are many persons who are unable to make a 
meal without it. Such a regimen is more likely to keep the 
disease stationary, and secure the general comfort of the 
patient, by upholding his strength, than by confining him to 
one kind of diet, which his stomach soon revolts against, and 
which must result in innutrition, general debility, the devel- 
opment of intercurrent affections, and sooner or later death. 
Enforced daily exercise in the open air, when possible, just 
short of fatigue, is as of much importance in the treatment 
of diabetes as diet. In Professor Bouchardat's estimation 
exercise is the most efficacious of agents. Gymnastics should 
be practiced. Trousseau says that he has repeatedly seen, 
during the hunting season, diabetic patients, abroad with 
their gun and dog, cease both to drink and urinate to excess, 
and regain their strength, and even their virile powers. A 
suit of flannel or buckskin should be worn next the skin. 
Warm alkaline baths should be frequently taken, and an 
occasional Turkish bath will be found serviceable, if it pro- 
duces no disposition to boils; or daily packing with the wet 
sheet may be tried, carefully watching the effects. The 
whole body should be hand-rubbed daily. Cream, so long 
as it agrees, may be permitted, and cod-liver oil is in many 
cases well borne, and would seem, as anourisher, to do good. 
The benefit of small doses of the alkalies, not continued 
longer than a week or ten days at a time, is incontestable. 
They are the best given in the form of Vichy, Marienbad 
Kreutzbrun, or Carlsbad Sproudel water. Legroux thought 
he derived benefit from the administration of arsenic. Dr. 
Richardson, of London, has recommended the respiration of 
oxygen, and Berenger-Feraud has shown that during its use 
there is great diminution in the amount of sugar in the urine 
(Bui. de Ther., t. lxvii). The ethereal solution of the 
peroxide of hydrogen (ozonic ether) has been given with as- 
serted benefit in half-drachm doses in an ounce of distilled 
water. Dr. T. K. Chambers has prescribed iodide of potash 
on purely empirical grounds. The preparations of iron are 



DIABETES MELLITUS. 99 

indispensable, and should be varied from time to time. To 
lessen the thirst and craving for food, small doses of opium 
are useful. By the use of the mixed diet recommended, par- 
ticularly if fatty articles can be taken, the obstinate consti- 
pation, so common in the earlier stages of the disorder, may 
be obviated without a recourse to drugs. Should this not 
be the case,castor-oil in capsules, or rhubarb and podophyllin, 
must be prescribed. 

" This mode of treatment, which secures a proper but va- 
ried diet, one that will not disgust the patient, but will nour- 
ish his body, though it may not remove the symptom glyco- 
suria, will, in a large number of cases, give the diabetic a fair 
share of conditional health; so that, as Dr. Trousseau re- 
marks, he would not know he had sugar in his urine, if an 
occasional chemical analysis did not remind him of its pres- 
ence." (Dr. Clymer's American edition). 

Nevertheless, there are, as Dr. Camplin justly observed, 
' certain fixed broad principles upon which the disease is to 
be treated." In all cases the various influences of the stom- 
ach, liver, skin, and kidneys on the nervous system and on 
each other, ought to be sought out and determined, and the 
basis of treatment arranged accordingly. It is necessary to 
abstain from all amylaceous food, as well as from every solid 
and liquid containing sugar, or any substance readily con- 
vertible into sugar. Fat meat and eggs may be taken, if 
biliary derangement is not induced by them, and fish is a 
most important article with which to vary the monotony of 
the dietary. Milk may also be indulged in occasionally, as 
it is not found that the sugar it contains is readily converted 
into glucose. Its influence, however, requires watching. 
The name of Dr. Donkin is associated with a special treat- 
ment of this disease in the use of skim-milk as the sole and 
only diet. He shows that in accordance with the teachings 
of chemistry and physiology we ought to expect advan- 
tageous results from it. Dr. Donkin contends that milk-sugar 
differs so essentially from cane sugar, grape sugar, and pure 
diabetic sugar, that it is not converted into it, and does not 
appear again in that form in the renal excretion. " Belong- 
ing to a different class of sugars, milk-sugar does not undergo 
alcoholic fermentation in contact with yeast; and, in addi- 
tion, it does not precipitate the oxide of copper when treated 
with the reduction test. On the other hand, it is subject to 
lactic fermentation by the action of ferments. On account 
of these intrinsic differences, lactose, as an ingredient of 



IOO DIABETES MELLITUS. 

milk, cannot undergo the same mctamorphic changes as glu- 
cose in the processes of digestion, and assimilation in health 
(nor be converted into it in diabetes); its conversion into 
lactic acid being direct and immediate, not by intermediate 
changes, through which the latter pass into this substance. 
For this reason milk-sugar, unlike vegetable glucose, is assim- 
ilated. It is necessary to notice, however, that milk-sugar, 
in the presence of acetic acid and some other vegetable acids, 
and of several mineral acids and other substances, was long 
ago observed by Simon to be changed into grape-sugar, and 
so became liable to alcoholic fermentation, and hence pre- 
sumably as injurious to the diabetic as glucose. Hence 
milk-sugar may be thus perverted and rendered poisonous 
by admixture with other articles in the stomach, whereas 
taken quite alone, it may be the best of foods to the hungry 
patient. It is not, then, considered to be a fair trial of Dr. 
Donkin's skim-milk treatment, if any other food be allowed to 
mix with it in the stomach. It must be made the exclusive 
article of diet. The use of lactic acid by Professor Cantani, 
Dr. Balfour, Dr. Foster, and Dr. Ogle, is quite dis- 
tinct from the treatment recommended by Dr. Donkin. 
They prescribed lactic acid as a remedy intended 
to make other foods wholesome; he prescribed skim- 
milk as a sole nutriment, which the mixture of 
other foods nullifies. As to the quantity demanded, it ap- 
pears that a patient can drink as much as a gallon and a 
half per diem: but that is an extreme ration; and when the 
appetite is so keen, Dr. Donkin advises some of the milk to 
be made into curd or "junkets.' 1 But much less than a 
gallon and a half will suffice, for much less will supply the 
calculated daily wants of the digestive organs. Each pint 
of skim-milk contains half its weight of casein in a fluid 
state, which, in fact, is liquid bodily tissue. There is 72 per 
cent, of water in combination with it, and there is 72 per 
cent, of water in the primest beef. Thus, in five pints of 
skim-milk a man would get as much nutriment as in 3^ lbs. 
of beef-steak, which, in an exclusively meat diet, may be 
reckoned sufficient even to do a day's work upon. Dr. Don- 
kin has, no doubt, made out a case for at least a temporary 
trial of this remedy in all but exceptional instances of dia- 
betes. But the treatment must be commenced in the earliest 
stages. I have not found it of any use when the disease is 
persistently established. 

It is desirable to vary the food as much as possible dur- 



■ DIABETES MELLITUS. IOT 

ing the day, taking the lighter kinds in the later meals. 
When soups are taken, they ought to be really good, and 
flavored with aromatics or onions, to the exclusion of car- 
rots, turnips, and peas. They may be thickened with some 
bran finely powdered. Lettuces Dr. Camplin found to agree 
well, when eaten sparingly with oil and vinegar, or with a 
little salt only, if the vinegar is likely to disagree. Pickles 
in small quantities may be permitted to convalescents. If 
cocoa agree, it may be taken, prepared from the nibs only. 
With regard to drinks: if milk is found to agree, it may be 
used as a drink combined with half its bulk of lime-water or 
soda-water, or in the form of what is known as " buttermilk " 
in Scotland and in Ireland, but which in England is gener- 
ally given to pigs, not yet being sufficiently appreciated by 
natives south of the Tweed. Dr. Camplin eventually found 
it necessary to abstain from all alcoholic drinks; but, where 
they are found desirable or necessary, a selection may be 
made from those wines and spirits which are freest from 
sugars. Of these, clarets may be chemically considered the 
best, then Burgundy. The so-called "fruity wines " must 
be entirely interdicted; and of all alcoholic beverages weak 
brandy and water is the safest. The amount of brandy 
must be always measured, and taken as directed by the 
medical attendant. From a teaspoonful to a tablespoonful 
in a tumblerful of water is generally sufficient for an ordi- 
nary dinner drink; and Dr. Camplin candidly and feelingly 
observes, from his own experience, that no diabetic need ex- 
pect to recover or continue well who cannot exercise self- 
control, and make up his mind to be temperate in all things. 
Seeing that under this system of diet the patient is deprived 
of the use of ordinary bread, Dr. Camplin devised a form of 
bread prepared solely from bran; and the great value of bran 
cakes as a substitute for bread in cases of diabetes has now 
been established by the experience of so many individuals 
that its use ought to be insisted on. The bran used should 
be thoroughly washed, so that it may be free from starch as 
possible, and finely powdered, so that it may not irritate the 
susceptible mucous membrane of the intestines. Such care- 
fully-prepared and finely-powdered bran may be obtained 
from Mr. Batchley, of 362 Oxford Street, London, near the 
Pantheon; also of Mr. Donges, Gower Street,London, North. 
But if it is desirable to prepare the powder at home as it is 
required, a special mill and sieve for the purpose are necessary, 
and may be obtained of Messrs. Evans Brothers, 54 Brick- 



102 DIABETES MELLITUS. 

lane, Spitalfields, London, E. (Dr. Camplin's* " Mono- 
graph on Diabetes.") 

Consistently with the experiments of Bernard, " cod-liver 
oil holds out some prospects of a natural plan of treatment 
by its use." Dr. Pavy recommends ground almond powder, 
made into biscuits, rusks, and bread, with eggs, as a substi- 
tute for ordinary bread. Mr. Hill, 60 Bishopsgate Street, 
London, makes such biscuits. 

An abstinence from water lessens the formation of sugar; 
but it probably accumulates in the 'body, so that when fluid 
is again given, an excessive elimination of sugar occurs 
(Ringer, Griesinger); and patients become extremely de- 
pressed and ill if water is withheld from them, probably from 
the impregnation of the body with sugar (Parkes). Coffee 
lessens the sugar, but increases the urea. Rennet, as recom- 
mended by Dr. Gray, of Glasgow, at first lessens the sugar 
and water; but they afterwards increase again. Warm baths 
lessen the amount slightly. When the diabetic symptoms 

* The formula for bran cakes is thus given by him: — " Take a quan- 
tity of wheat bran (say a quart). Boil it in two successive waters for a 
quarter of an hour, each time straining it through a sieve; wash it well 
with cold water on the sieve, until the water runs off perfectly clear. 
Squeeze the washed bran in a cloth, as dry as possible, then spread it 
thinly on a dish, and place it in a slow* oven. When it is perfectly dry 
and crisp it is fit for grinding into fine powder. The bran thus prepared 
is ground in the mill for the purpose, and must be sifted through a wire 
sieve of such fineness as to require the use of a brush to pass it through, 
and what remains on the sieve must be reground till it is sufficiently 
soft and fine. To prepare a cake, take of this bran powder three or four 
ounces, three new-laid eggs, one and a half or two ounces of butter, 
and about half a pint of milk. Mix the eggs with a little of the milk, 
and warm the butter with the remainder of the milk; stir the whole well 
together, adding a little nutmeg and ginger, or any other spice that may 
be agreeable. Bake in small tins (patty-pans, which must be well but- 
tered), in a rather quick oven, for about half an hour. The cakes when 
baked should be a little thicker than a captain's biscuit. These cakes 
may be eaten with meat or cheese for breakfast, dinner, and supper, 
and require a free allowance of butter; and the cakes are more pleasant 
if placed in the oven a few minutes before being placed on the table. 
When economy is an object, when a change is required, or if the stom- 
ach cannot bear butter, the cakes may be prepared as follows: — Take of 
the prepared bran four ounces, three eggs, about twelve ounces of milk, 
with a little spice and salt, to be mixed and put into a basin (previously 
well buttered). Bake it for about an hour; the loaf may then be cut into 
convenient slices and toasted when wanted; or, after slicing, it may be 
rebaked, and kept in the form of rusks. Nothing has yet been discov- 
ered of equal utility to these bran cakes, combining, as they do, moderate 
cost with freedom from starch, and sufficient pleasantness as an article 
of food." (Camplin, " On Diabetes," third edition). 



DIABETES MELLITUS DIARRHCEA. 103 

subside, congestions, especially of the head, are apt to super- 
vene. Such congestion Dr. Camplin found to subside grad- 
ually under the use of citrate of ammonia and small doses 
of colchicum wine. Warm flannel ought to be worn next 
the skin in all cases, and residence in a warm climate will 
often be of service as an aid to the means of cure employed. 

The great difficulty in the treatment of diabetes is to man- 
age the dyspepsia and impaired digestion, and, at the same 
time, to diminish and keep in check the formation of sugar. 
The first principle consists in varying the alimentation so as 
to prevent disgust; the second is to add fatty aliments in 
proper proportion to the alcoholic aliment, the exaggerated 
use of the latter acting injuriously on the nervous system; 
and the third is to suppress or considerably diminish for 
some time the use of feculents. 

Diarrhoea. — Definition. — A frequent discharge of loose 
or fluid alvine evacuations, without tormina or tenesmus 
(Good, Copland), in which the intestinal lesion varies from a 
mere condition of irritation, expressed by the increased and 
modified secretion (beyond which it does not progress), to 
those cases in which there is actual inflammation or other 
lesion of mucous membrane, the latter being a higher degree 
of the former, the cases passing from one to another by in- 
sensible degrees (J. J. Woodward). 

The treatment of diarrhoea may be founded on the 
following indications: (i.) When the tongue is clean, 
the pulse quiet, and all constitutional reaction absent ; 
(2.) when the tongue is white and coated, the pulse ac- 
celerated, some fever present, and the pain or soreness con- 
stant and increased by pressure. The stools in either case 
may be black, green, white, or mixed with blood indifferently. 
When the tongue is clean, if the disease be quite incipient, 
one dose of an opiate may be given, combined with a gentle 
cathartic. The form may be one grain of opium, combined 
with a drachm of compound rhubarb powder, or with three 
to five grains of calomel. To remove any offending matter 
that may be present, the action of the bowels may be aided 
by castor oil, or a saline cathartic, such as a seidlitz powder 
or compound senna mixture. Sometimes it may be advisable 
to omit the opium, and to combine antacid remedies with the 
laxative, as in the following prescriptions : 

^,. Sodae Bicarbonatis Hydrargyri cum creta, a a gr. ii, 
ad gr. v.; Magnesise Carbonatis, gr. iii. ad gr. vi.; Pulv. Rhei. 
gr. v. ad gr. viii.; misce. Or — 



104 DIARRHCEA. 

3 . Sodse Bicarbonatis ; Pulv. Rhei ; Pulv Calumbae, a a 
gr. iv. ad gr. vi.; misce. 

The administration of such a powder may be repeated at 
intervals — twice or thrice a day ; and ipecacuanha in small 
doses (a quarter or a sixth of a grain) may be advantageously 
combined with each dose. Other more astringent remedies 
may be administered if diarrhoea persists. In many cases a 
drachm of syrup of poppies after each stool is sufficient to 
arrest it. In severe diarrhoea a scruple to half a drachm of 
the compound chalk powder, in some aromatic (peppermint 
or cinnamon water,) every four or six hours, may be used 
whether blood be or be not in the stools. If the opiate and 
aromatics should prove insufficient, it may be necessary to 
add to each dose some of the class of pure astringents, as a 
drachm of the tincture of kino, or of catechu, or of haema- 
toxydon, or of iron. The following formula (Diarrhoea Mix- 
ture) has been found of service : 

3. Conf. Aromat., 3 ii j . ; Sodse Carb., 3 iss. (Bicarb.); 
Tinct. Opii., 3 i.; -^Ether Chloric, 3 ii j . ; 01. Caryoph., m xl.; 
Mucilag. Acaciae, fi.; Aquae Destil., ad fv.; misce. One 
teaspoonful for a dose. This quantity may be given every 
two or three hours, or every hour, or every half hour, should 
the purging continue. 

Absolute rest in the recumbent posture must be maintained, 
and warmth applied to the surface of the abdomen. Bland 
demulcent food, such as arrow- root, with beef-tea or gruel, 
may be taken. 

There are cases of diarrhoea with a clean tongue, which 
will not yield to laxative remedies, nor to opiates, astringents, 
or stimulants, either singly or combined, which probably de- 
pend on a want of tone in the intestine, associated with de- 
composition of intestinal contents and fetid stools. In these 
cases five grains of salicine every four or six hours have often 
stopped a diarrhoea that appeared fast hurrying the patient 
to his grave. Salicylic acid and salicylate of soda have also 
been found useful. Tincture of the sesquichloride of iron is 
similarly useful in doses of five to ten minutes. In the di- 
arrhoea of whitish stools, with frequent calls and sudden de- 
sire to evacuate the rectum, when muco-gelatinous matter 
like a jelly is passed, no remedy is of so much service as the 
extract of nux vomica, to the extent of a fourth to a half grain 
dose ; or strychnia, to the extent of one-twelfth of a grain, 
in a pill twice or thrice a day, with the sulphate of iron and 
extract of calumba. Tincture of the pernitrate of iron 



lUARRHCKA. I05 

(m x. every half hour) may be given with great benefit (W. C. 
Maclean). It is in diarrhoea of this kind that iron is of so 
much service. The ferri ammonia-phosphas possesses some 
desirable properties, especially as to solubility and freedom 
from the inky astringent taste of preparations of iron. Its 
preparation is given in the following note : [Ferri Ammo- 
nia-Phosphas. — Heat common phosphate of soda to redness. 
Take of the pyrophosphate of soda so obtained 3 ij. Dis- 
solve in one pint of warm water. Then take of protosul- 
phate of iron 3 iv. Dissolve in twelve ounces of water. Mix 
the solutions, collect, wash, and dry the precipitate at a gen- 
tle heat over a water-bath. Take of this precipitate 3 j., 
Liq. ammonia P. L., f iss., water q. s. Dilute the Liq. ammo- 
nia with an equal volume of water, and rub up with the phos- 
phate of iron in a mortar until the latter is dissolved. Then 
dilute to 3 viij. Filter the solution, and evaporate at a heat 
not exceeding 120° Fahr., over a water-bath, and proceed as 
for the other scale preparations of iron. The dose is one fluid 
drachm (W. H. Moss, Dispenser, A. H. C.) In fluid extract of 
coto bark (prepared by Ferris & Co., Bristol), we have also a 
useful remedy in doses of five to eight minims. Black or 
dark stools (melaena) are not so much due to bile (atrabilis of 
Abernethy) as that such stools, resembling pitch, are princi- 
pally composed of morbid or impaired secretions from the 
intestines (Hoffman, Home, Graves). The discharge of the 
black matter is followed by a feeling of relief to the system 
generally. In cases of true melaena (where the dark color is 
due to blood), great debility, and sometimes fainting, may 
follow the evacuations. Stimulating and tonic remedies, 
such as turpentine, are of benefit (Graves). When diar- 
rhoea is accompanied by a white furred tongue, with pain 
and soreness, it is necessary to give opiates, combined with 
some mild purgative. Half a drachm to a drachm of Epsom 
salts, with a drachm of the syrup of poppies ; or fifteen min- 
ims of the tincture of hyoscyamus ; or, in severe cases, with 
three to five minims of tincture of opium, every four or six 
hours, are remedies on which, as a general principle, we may 
very confidently rely. In other cases, rhubarb, castor-oil, or 
any other mild purgative, may be substituted for the Epsom 
salts. In cases of diarrhoea, accompanied by vomiting, a 
drachm of syrup of poppies alone, repeated every half hour, 
or every hour, for two or three times, may quiet the stom- 
ach, and enable it to bear other remedies. Soda-water, or 
the effervescing draught, with a tablespoonful of brandy, with 



Io6 DIPHTHERIA. 

or without a few minims of tincture of opium, often remain 
on the stomach when everything else is rejected. 

Most practitioners lay great stress on the color of the 
stools, and the necessity of correcting the supposed mor- 
bid states of the liver ; but the various colors of the stools 
are in many instances caused rather by morbid secretions 
from the surface of the mucous membrane of the intestines 
than by any defective state of the bile in the gall-bladder. In 
simple diarrhoea, mercury (which is so often given in a routine 
way) in any form is either unnecessary or injurious in the ma- 
jority of cases, except as a purgative. It is, however, some- 
times necessary, especially in children under four years of age. 
One general rule may be acted on— namely, that in the adult, 
whatever be the form of the diarrhoea, if the stools be dark 
at first, and then become light-colored, purgative medicines 
are no longer beneficial. In no instance ought they to be 
continued longer than is sufficient to remove any irritative 
substances accumulated in the alimentary canal. Sulphuric 
acid, in doses of the officinal or aromatic diluted drug, of 
twenty to thirty drops, with water simply, or combined with 
the compound tincture of gentian, has been found a useful 
remedy. It may be alternated with the diluted nitro-muri- 
atic acid, and prescribed in a similar manner. The dietetic 
treatment should be limited to slops, puddings, and white fish 
boiled, and the drink to weak brandy and water, which acts 
locally as an astringent, and generally as a diffusible 
stimulus. 

Diphtheria. — Definition. — A specific disease commencing 
with fever, and producing a membranous exudation in and 
upon the mucous membrane (of one or other, or all of 
it) covering the tonsils, uvula, and soft palate, the root of the 
tongue, the larynx and air passages, the posterior wall of the 
pharynx, or the nasal cavities. The disease is attended with 
great prostration of the vital powers; also, by a very early 
appearance of albumen in the urine, which may continue for 
a very short time only, or may become persistent. In many 
cases a remarkable series of nervous phenomena are apt to 
supervene, characterized by progressive paralysis, and some- 
times by fatal syncope. The disease is contagious, and apt 
to be epidemic. 

Treatment — There are especially three things it is desira- 
ble to bring about, namely: — (i.) Softening or suppuration of 
the exudation and its connections — to convert the process 
into a catarrhal one; (2.) to thoroughly disinfect the air pas- 



DIPHTHERIA. I07 

sages; (3.) to overcome the marked asthenia by which all 
cases of this disease are marked (Wagenen). To accomplish 
the first, vapor of water at a temperature of 120 to 130° 
Fahr. should be inhaled continuously for fifteen or twenty 
minutes every hour; and where the exudation is considera- 
ble and tough a very hot poultice should be applied extern- 
ally, or compresses wrung out of hot water and covered with 
oil-silk should be used. Under such means the exudation 
may break down into a suppurating mass in from twelve to 
twenty-four hours; but the deposit may return again, if the 
vapor inhalation is omitted too early. Even in those cases 
which die, this method of treatment accomplishes euthanasia. 
The temperature of the room in which the patient is confined 
to bed ought to be kept at 68° Fahr., and its atmosphere 
kept moist by the steam from a kettle with a long spout con- 
stantly boiling on the fire, and by large basins placed about 
the room, and kept constantly full of hot water. If the pa- 
tient can be enveloped in a warm moist atmosphere, so much 
the better; and this may be done by making a tent with 
blankets over the bed, and, by the aid of a spirit lamp, a tin 
kettle of boiling water may be maintained at the boiling 
point, and its steam thus made to envelop the patient. The 
steam assists very much in dissolving the mucus and in loos- 
ening and breaking up the membranous deposit. To accom- 
plish the second indication — namely, disinfection — acetic, 
salicylic, or carbolic acid, or sulphurous acid may be used. 
Neither is a specific. A wineglass of vinegar to a pint of 
water is a good proportion (Sir W. Jenner). The solutions 
ought to be made as strong as the patient will bear them; 
and should be used with the vapor of water as a spray in a 
steam-atomizer, as well as by gargling. The steam antiseptic 
spray is the best, as the steam carries the disinfectant to 
every part of the diseased surface; while the vapor which 
escapes into the room is also a carrier of the antiseptic, as it 
is of caloric, when a large room is heated by dripping water 
on a hot plate or stone. 

Syringing the throat and nares with the perchloride of iron 
in solution is also very beneficial. The solution ought to 
consist of tincture of perchloride of iron, and of glycerine, 
each half a drachm, with two or three drachms of water. A 
stronger solution — the strength of the tincture — may be ap- 
plied with a large camel's-hair brush to a patch of exudation, 
and the adjacent surface of the mucous membrane; or a pre- 
paration, twice the strength of the tincture, may be made by 



I08 , DIPHTHERIA. 

mixing equal parts of the liquor ferri perchloride and of 
glycerine, and may be used to brush over the patches if the 
exudation is very thick. But such an application, as it is 
powerfully styptic, should be confined to the surface of the 
exudation only. It readily penetrates it, and exerts its bene- 
ficial influence on the vessels below (Squire). In short, the 
application of this remedy to the whole of the pharynx with 
food, or separately as a lotion, to be applied as a gargle, or 
a medicine to be swallowed, affords relief. 

With regard to topical applications, Sir Wm. Jenner is of 
opinion that repeated applications to the throat of caustic 
solutions are injurious. He recommends one single but effi- 
cient application of a strong solution of nitrate of silver (3i. 
to 3 i- of water), as a remedy which may stay the spread of 
the exudative inflammation; but that, on the whole, hydro- 
chloric acid and water in equal parts will more frequently 
attain the object. It is especially the surface round the ex- 
udation, as well as the exudation itself, that should be painted 
well over with the solution, the brush being passed over the 
surface two or three times in quick succession. The white 
discoloration which results must not be confounded with the 
spread of the diphtheritic exudation. The discoloration 
from the acid passes away in about thirty-six hours, and that 
from the nitrate of silver somewhat quicker. Medicinal car- 
bolic acid (as prepared by Calvert, of Manchester) is valu- 
able as a gargle, in the proportion of i of acid to 200 parts 
of water. 

There are considerable differences of opinion regarding 
the usefulness of topical applications, and the best means of 
applying them. The tincture of the perchloride of iron is 
recommended by some to be gently painted over the fauces, 
as already directed. The throat should be washed out as 
often as possible with permanganate of potash (1 to 300), or 
with lime water in a solution of chlorate of potash. The 
local application of lime water by frequent gargling or gentle 
brushing, with the internal administration of nitrate and car- 
bonate of soda, prove speedily curative in the milder cases, 
and alleviate distress in the more severe. Ice kept dissolv- 
ing in the mouth "is often also a great comfort, and its use 
should never be omitted where it can be had. Dr. Green- 
how remonstrates against the application of the more severe 
topical remedies. The pellicle or false membrane ought 
never to be torn off. The bowels should be opened freely 
by a dose of calomel and jalap; or by calomel and colocynth 



DIPHTHERIA. IO9 

pill, followed in the inflammatory or sthenic forms of the dis- 
ease by a saline aperient — e. g., sulphate of magnesia in the 
infusion of roses. If feebleness of pulse supervene, if the 
redness of the throat assume a dusky hue, if the sense of 
general weakness become extreme, wine in large doses fre- 
quently repeated is required. Six or eight ounces of port or 
sherry during the day for an adult may be given from the 
first, with as good a diet as the stomach can digest. During 
the course of the disease, much larger quantities of wine and 
even brandy may be necessary; but the quantity of stimu- 
lants must be regulated by the habits and age of the patients. 
A child of three years of age may take with advantage one or 
two drachms of brandy every hour — i. e. } from three to five 
ounces of brandy during the twenty-four hours (Sir Wm. 
Jenner). So long as there is firmness of pulse the physician 
ought to abstain from alcoholic stimulants, and rest con- 
tented by giving such saline medicines as exert a slight action 
on the skin and on the kidneys, or on both. But a rapid 
pulse indicates the necessity of alcoholic stimulants, which 
ought to be freely given on the development of the earliest 
general symptoms. Under all circumstances efficient daily 
action of the bowels must be secured, and the urinary and 
intestinal secretions should be examined daily. If blood or 
albumen appear in the urine, diuretics are contraindicated. 
Mustard poultices, warm linseed-meal poultices, or the warm 
wet sheet, as recommended by Dr. Huss in typhoid fever, 
may be applied to the loins under these circumstances. The 
hot-air bath applied to the body, without removal from the 
bed, is also of great service. Diphtheria is most successfully 
treated by the administration of mineral acids, especially the 
nitric and hydrochloric; also by guaiacum, chlorate of 
potash, quinine and iron. Tincture of the perchloride of 
iron is now fully recognized as having a beneficial local as 
well as general influence on the disease; and it may be ad- 
vantageously combined with quinine in the following formula 
(Tanner): 

fy . Quiniae Sulphatis, gr. ii. ; Acidi Hydrochlorici diluti, 
m x.; Tincturae Ferri Perchloridi, m xv. ; Infusi Calumbas, 
I i.; misce. Fiat haustus, omnibus sextis horis sumendus. 

As soon as nourishment can be retained by the stomach 
five to ten grains of the perchloride of iron, equivalent to 
twenty or forty minims of the tincture, combined with half a 
drachm of glycerine and half an ounce of water, should be 
given, and repeated every three or four hours (Squire) It 



110 DIPHTHERIA. 

should be commenced on the first day of the Illness, or as 
soon as the nature of the disease is recognized. Evidence 
of its good effects are shown by a diminution of the secre- 
tions from the fauces and throat, and improvement in gen- 
eral symptoms. Guaiacum is of service in keeping the bowels 
open. It ought to be given in the form of the rectified spirit 
tincture, to the extent of one drachm combined with two 
drachms of glycerine for a dose, as recommended by Dr. 
Balmanno Squire. This makes a clear solution, to which no 
water must be added. 

The third indication — namely, to overcome the marked 
asthenia — restoratives are demanded, and feeding is all-im- 
portant in the treatment of diphtheria. The night should 
never be passed without either nourishment or stimulant be- 
ing given; and the quantity of liquid nourishment and of 
stimulant given in the twenty-four hours must be equal 
to the estimated requirement of the patient (Squire). 
A young child (one to two years) may require a teaspoonful 
of brandy every two hours; a child of three years, two tea- 
spoonsful, diluted, and given in small portions at a time. 
Milk, beef-tea thickened with arrow-root, milk punch, are 
most useful alteratives. By so averting death, time is gained 
for the general disease to run its course (Jenner). 

Tracheotomy is of little avail in diphtheria, and the sole 
object contemplated by an opening in the windpipe is the 
prevention of death by suffocation. Nevertheless the opera- 
tion is indicated in every case where the larynx is blocked up 
by membranous or pseudo-membranous formation; when we 
can scarcely ever anticipate that the disease will subside in a 
few days, and before fatal suffocation occurs. The condi- 
tion of the patient is generally improved for the time by the 
actual operation, if it is not too long deferred, or done in the 
death-agony. It is also especially done to gain time; and it 
is also indicated whether the impediment to respiration is in 
the larynx only, or whether it extends farther down, or 
whether secondary changes have already taken place in the 
lungs. In the two latter cases the chances of recovery are 
generally very much less; but the operation of tracheotomy 
does not make the prospects worse for the patient; and it 
should be done when the existence of a more than merely 
catarrhal affection of the larynx is indicated by great diffi- 
culty of breathing, continuing more than two or three days; 
or by attacks of suffocation. The operation will not cure 
the disease. In this respect it differs greatly from croup; 



DROPSY DYSENTERY. Ill 

and it is chiefly in cases of croup, as distinguished from diph- 
theria, that tracheotomy is attended with such favorable re- 
sults. (See under Croup.) Tracheotomy, if not too long de- 
layed, saves many a life in croup. 

In the consecutive paralyses tonics and local galvanism are 
the most important remedies, and the bowels should be kept 
open by a pill, taken morning and evening, containing from 
a quarter to half a grain or a grain of the extract of nux 
vomica, with a like quantity of sulphate of iron, combined 
with two or three grains of compound rhubarb pill mass. 
These may be varied with the administration of pills con- 
taining -^ 2 of a grain of strychnia, the strychnia being tritu- 
rated with sugar of milk, and made into pills with a sufficient 
quantity of extract of gentian. Syrup of the phosphate of 
iron in fluid drachm doses may be given twice a day (com- 
bined or not with liquor strychnia) ; and stimulants in the 
form of malt liquors, especially stout (if free of cocculus in- 
dicus), are beneficial if taken with or after meals, and the 
doses of iron may be taken at the same time. The syrup of 
the phosphate of iron, quinine, and strychnia I have also 
found of great use. 

Dropsy, General. — See Anasarca. 

Duchenne's Disease. — See Paralysis, Bulbar. 

Dysentery. — Definition — A febrile disease, accompanied 
by tormina, by straining, and by scanty mucus or bloody 
stools, which contain little or no faecal matter. The minute 
lenticular and tubular glands of the mucous membrane of 
the large intestines, with the intertubular connective tissue, 
are the chief seats of the local lesion, which sometimes ex- 
tends into the small intestine beyond the ileo-caecal valve, as 
in cases in which scorbutus is a predisposing cause. Under 
some circumstances it is infective. 

Treatment — It is the obvious duty of the physician to direct 
his attention, in the first instance, to the prevention of the 
disease. He must enquire especially as to the conditions of 
the diet, that it be sufficient as to its animal and vegetable 
elements, and of good quality. Next, he ought to ensure the 
means of detecting the disease early — for time is of the 
greatest importance in its cure. He must remove the patient 
from the sphere of action of any of the predisposing or ex- 
citing causes, and see that his surroundings are free of all 
those circumstances which co-operate in aggravating the dis- 
ease, the chief of which are overcrowding, bad ventilation, 



112 DYSENTERY. 

bad food, exposure, and intemperance. With regard to med- 
icinal agents my friend and colleague, Professor Maclean, has 
written me the result of his extensive experience in India and 
China: — He is of opinion that the first thing to bear in mind 
in the treatment of tropical dysentery is, that the appearance 
of strength in the patient, given by the acuteness of the 
symptoms, is delusive. Under the use of antiphlogistic 
treatment the strength of the patient is apt to fail suddenly; 
and this is often the case, even when the treatment has been 
more conservative in its character. It was, once the custom 
in India to deplete freely in this disease, either by a general 
bleeding or by the repeated application of leeches; but, the 
most judicious and successful practitioners in India rarely 
bleed now, even in the most asthenic forms of the disease, 
and confine the use of leeches within the narrowest limits. 
It is certain, too, that mercury is yearly less and less used in 
India than it was; and there is much evidence to show that a 
corresponding reduction in the mortality of the disease has 
been the result. The objections to its use are numerous, — it 
entails great suffering on the patient, if pushed to ptyalism, 
aggravating his miseries, and too often permanently injuring 
his constitution; it has no specific action on the disease, and 
its cholagogue effects can be attained by remedies which are 
not open to such objections as can be brought against mer- 
cury. In sloughing dysentery it is followed by the worst re- 
sults; and the observations of clinical observers in India 
have shown that individuals under the influence of mercury 
are not only not exempt from attacks of the disease, but are 
peculiarly prone to be affected by it. This is the case in a 
very marked degree in Asiatics (Morehead and Maclean). 

Ipecacuanha, in the radix anti-dysenterica, has long been 
used in South America in the cure of dysentery, — whence, 
indeed, it came. It was much used in India until the mer- 
curial notions of James Johnston prevailed. It was again 
used by Dr. Twining, of Bengal, by whom it was strongly 
recommended, and also by Dr. Mortimer, of Madras. Twin- 
ing combined it with blue pill and gentian, and used it chiefly 
in small and oft-repeated doses. In South America the prac- 
tice has always been to administer an infusion of the bruised 
root, — 3 ii. being infused over night in 3 iv. of water, and 
given early in the morning. In Peru it is given in doses of 
3 ss. to 3 i. of the powdered root in a little syrup and water. 
This practice of giving ipecacuanha in large doses has lately 
been revived in "India with encouraging success,, and Dr.. 



DYSENTERY. II3 

Maclean believes, with the greatest number of cures. It ap- 
pears to act on the portal capillaries, and on those of the 
mucous membrane of the bowels, and to determine power- 
fully to the skin. It is usually given in doses of half a 
drachm or a drachm, either in pills or bolus, or suspended in 
mucilage, according to the fancy of the patient. It is advisa- 
ble to give an opiate half an hour before, and to withhold all 
drink for some hours. Unless there be hepatic complica- 
tion, it seldom happens that much vomiting is caused by 
these large doses; on the contrary, they are often tolerated 
when smaller doses are rejected. The dose should be re- 
peated in about six hours. A sufficient interval should be 
allowed to intervene between the doses of ipecacuanha, to 
admit of the patient being sustained by nourishment adapted 
to the stage of the disease. Dr. Cornish, of the Madras 
army, .has shown from official documents, that the mortality 
from acute dysentery in Southern India under mercurial 
treatment was 7.1 per cent. Since the general introduction 
of ipecacuanha in full doses it has fallen to 1.3. Dr. Ewart, 
of Bengal, has shown that equally good results have follow- 
ed the same system in that Presidency. During the forty- 
two years, from 181 2 to 1853-54, the mortality among Eu- 
ropean troops in the Bengal Presidency amounted to 88.2 in 
the thousand. But during i860, when large doses of ipecac- 
uanha were administered, the mortality was only 28.87 in the 
thousand. Although highly useful in some conditions, it is 
not to be regarded as a specific in all forms of the disease. 
It is more effectual in the sporadic and mild acute cases than 
in the chronic forms. Its use should be limited to vigorous pa- 
tients with acute catarrhal diarrhoea or dysentery; or with 
the preliminary catarrhal stage of diphtheritic dysentery 
(Woodward). The large dose method of its administration, 
which now prevails, is to give as early in the disease as pos- 
sible grs. xxv. to xxx. of ipecacuanha in as small a quantity 
of fluid as possible. A preliminary dose of opium may be 
of service in enabling the stomach to retain the ipecacuanha. 
It can be swallowed in the form of a bolus, by wrapping-it in 
soluble tissue paper. The patient should then remain per- 
fectly still in bed, and abstain from fluid for at least three 
hours. If thirst is urgent it may be appeased by sucking 
small bits of ice, or taking not more than a teaspoonful of 
iced water. In from eight to ten hours, from 10 to 15 grains 
may be again administered, with the same precautions as be- 
fore. The beneficial results are manifested by the tormina 



114 DYSENTERY. 

and tenesmus subsiding, the motions becoming feculent, blood 
and slime disappearing; and often, after profuse perspiration, 
the patient falls into a tranquil sleep and awakes refreshed. 
The ipecacuanha may require to be continued in diminished 
doses for several days, with sufficient intervals between each 
dose to admit of food being taken; and for several nights 
after the stools appear normal, grs. x. to xii. of ipecacuanha 
should be still given at bedtime. Astringents in any 
shape during the acute stage are not only useless but 
dangerous (Maclean, Docker, Waring). Blood-letting has 
now been totally superseded and rendered unnecessary by the 
use of ipecacuanha. Ergot has been used in an enema to the 
extent of 12 or 15 grains in some bland fluid; or in 6-grain doses 
by the stomach, in cases of epidemic dysentery, with the 
beneficial result of reducing the quantity of blood in the 
stools (Dr. Gros, Practitioner, Nov., 1868). Opium is not 
to be regarded as a specific or curative agent, either in acute 
or in chronic fluxes. Its use should be restricted to the 
fulfillment of two indications, namely: — (1.) to relieve pain; 
(2.) to procure sleep. Chronic opium intoxication is to be 
avoided, by suspending its administration, or by alternating 
it with other remedies. Hypodermic injections of morphia 
give the best anodyne or soporific effects. It is most fre- 
quently indicated in cases of acute gastro-intestinal catarrh. 
In alcoholic conditions it may be of advantage to combine 
chloroform with the morphia, repeating the dose after an 
hour's interval. Dover's powder, — Pulv. ipecacuanha com- 
posita, is of service in full doses of grs. x to xv. at bedtime, 
followed up by a five-grain pill of the same, taken every 
four or six hours for two or three days, or till relief is ob- 
tained. In smaller doses, frequently repeated, it may be 
combined advantageously with nitrate of silver (Waring). 

In mild cases, but where the pains are excruciating and 
attended with tenesmus, the warm bath generally gives in- 
stantaneous relief in cases following chills, if adopted suffi- 
ciently early. Dr. Maclean directs that it be brought to the 
bedside, and kept at a high temperature (not under 99 or 
ioo° Fahr.), the patient to remain in it till he feels faint. 
He is then to be carefully and quickly dried, put to bed, 
and have grs. xv. to xx. of ipecacuanha. Woodward objects 
to the hot bath except in chronic fluxes. Leeches, to the 
number of six to twelve, applied round the verge of the anus, 
often afford sensible relief to the tormina and tenesmus, by 
unloading the portal and hemorrhoidal veins (Waring). 



DYSENTERY. 1 1 5 

In subacute and chronic dysentery, " no remedy has proved 
more useful than nitrate of silver, in doses of half a grain to 
one and a half grains daily, reduced to a fine powder, and 
conjoined with Dover's powder in the form of a pill (Dr. 
Waring). It has also been extensively used in the form of 
enema, as follows : — First throw up into the transverse colon, 
by means of a flexible stomach-pump tube, introduced to 
the extent of six or seven inches, very cautiously and gently, 
enemata of warm water, or milk and water, to the extent of 
three, four, or six pints, so as to bring away any faecal ac- 
cumulations. Then follow up this practice by the injection 
of two and a half to three pints of distilled water, holding in 
solution gr. xv. of nitrate of siver " (Hare, Waring). 

In chronic cases a combination of sulphate of copper and 
of opium is often highly serviceable (J. Brown, Raleigh, 
Waring), in the following formula: — 

fy Cupri Sulph., gr. % to y 2 \ Pulv. Opii, gr. ^. Make 
a pill or powder, of which three are to be taken daily. 

Five grains of Dover's powder may be substituted for the 
opium. 

Solution of the pernitrate of iron is highly commended by 
Professor Maclean. It is astringent and tonic in doses of 
mx. to mxv. diluted in water. It may also be used as an in- 
jection. 

Nux vomica, combined with opium and iron, may be of 
use (Graves). In malarial dysentery, full doses of quinine 
(not less than twenty grains) ought to be given in acute cases 
before giving ipecacuanha, and it should be continued till 
there is evidence of cinchonism. The two drugs should then 
be given in alternate doses till the characteristic good results 
of each are produced (Maclean). The bark of the root of 
calotropis gigantea (or mudar) has been recently used in 
India, and is said to be an excellent substitute for ipecac- 
uanha. It is used in doses of a scruple to a drachm, is a re- 
liable cholagogue, and sedative to the muscular fibres of the 
intestine, rapidly allaying pain, tenesmus, and irritation 
(Durant, Lid. Med. Journ., May, 1866). On the Continent 
the neutral salts and mild purgative medicines are highly 
spoken of. Sulphate of soda is to be preferred to sulphate 
of magnesia (Mery, J. J. Woodward). It induces a decided 
increase in the hepatic secretion, which the Epsom salt fails 
to do (Rutherford and Vignall). Phosphate of soda and 
Rochelle salts are, for similar reasons, to be preferred to the 
Epsom salt, which is the least desirable of saline purgatives 



Il6 DYSENTERY. 

in dysentery. Castor-oil is similarly objectionable. It has 
no stimulating action on the hepatic secretion. In the treat- 
ment of chronic dysentery in the Seaman's Hospital, London, 
the Senior Physician, Dr. C. H. Ralfe, states that having 
watched 200 cases, he recorded in 1876 that those who lin- 
gered the longest, or at length did well, had little or nothing 
to owe to therapeutics, an opinion concurred in by Dr. 
Stephen Ward. He now abstains from action and special 
treatment, except to meet occasional and urgent symptoms, 
and places more reliance on the good effects of rest and diet. 
He has, however, systematized the administration of castor- 
oil, by giving it on stated days, at least twice a week. It re- 
moves retained scybalous faecal matter and irritating dis- 
charges, and prevents their accumulation. Some had bismuth 
mixture in addition, others had ipecacuanha (12 to 20 
grains), in single doses, repeated, if necessary, on second or 
third day whenever a relapse or return to the acute form 
was threatened. Sixteen out of thirty-eight cases were dis- 
charged cured; in nine of whom the duration of the disease 
prior to admission had averaged 18 months, and none less 
than five months. In painless diarrhoea and in chronic 
fluxes bismuth is of use after evacuants. From mercurials 
no advantages are to be expected that can counterbalance 
the serious objections to their use; but the benefit of the 
alterative effects of the remedy may be obtained by minute 
doses of corrosive sublimate. In certain cases of chronic 
dysentery Parkes found it most useful commencing with 
doses of one eighth to one sixth of a grain in combination 
with preparations of cinchona. It increases the hepatic 
secretion. Ringer gives the 100th of a grain every hour or 
every two hours, alike in acute and chronic dysentery. 

Dr. Bryson writes that he has seen all the astringents, both 
mineral and vegetable, mercury both internally and exter- 
nally, with many other medicines, tried without any benefit; 
but there were some means which were useful in relieving 
the more urgent and distressing symptoms. Amongst these 
he mentions a well-regulated farinaceous diet, opium suppo- 
sitories, anodynes, astringent injections, in combination with 
opium, cascarilla, resinous astringents, and the application 
of leeches to the rectum when tenesmus was distressing, or 
over the course of the colon when there was deep-seated 
pain. An injection of warm starch (two ounces) with laud- 
anum in it, will often give great relief. As much nourish- 
ment should be given in a liquid form as the patient can be 



DYSPEPSIA. 117 

got to take. Milk boiled with flour or arrow-root and bar- 
ley-meal should be taken as often as possible, night and day. 
It should be taken cold, even with ice, and in small quantities 
at a time; and small pieces of ice not only allay sickness and 
nausea, but seem to soothe the irritability of the intestines. 
Strong beef-tea, or Liebig's extract of flesh, are most useful. 
The value of a change of climate as a curative measure is 
forcibly illustrated by Dr, Bryson. He says that the crews 
of vessels improve in health almost immediately after quit- 
ting the station where dysentery prevailed. Where sewage 
is applied to the soil by surface irrigation, it ought to be di- 
luted largely with water, and deodorized by carbolic acid. 
In the scorbutic form we have a valuable remedy in the 
Bael fruit, which contains a large quantity of tannin, with 
vegetable mucus, a bitter principle, and a vegetable acid. 
It is much used in Bengal; and in the scorbutic form Dr. 
Maclean has seen it successful when all other measures have 
failed. 

Dyspepsia. — Definition. — Impairment of digestion, aris- 
ing without perceptible change of structure or lesion of the 
stomach. 

Treatment. — Congestion, catarrh, and functional states as- 
sociated with what are called dyspeptic symptoms, or " im- 
perfect digestion," are the results of stomach diseases for 
which the physician is called most frequently to prescribe. 
When there is reason to believe congestion exists, a sparing 
and easily digested diet is to be prescribed, with total absti- 
nence from fermented drinks ; and in cases where catarrhal 
inflammation prevails the blandest food must be given in 
very small quantities. In severe cases leeches are to be ap- 
plied over the region of the stomach, and the patient may 
sip iced tea, or suck small pieces of ice, to relieve thirst. In 
impaired digestion from any cause, a mode of life tending to 
improve nutrition is to be aimed at. The necessity of strict 
attention to diet in all cases of impaired digestion is abso- 
lute. • If fulness and uneasy sensations are experienced after 
dinner, less food should be taken at that meal, and more at 
breakfast ; the principle being to apportion the amount of 
food necessary to sustain the body more evenly over the 
waking hours than is commonly done. The great fault in 
the dietetic system of this country consists in most people 
supporting themselves mainly by dinner. This meal is con- 
sequently too large ; and the quantity taken at dinner should 



Il8 DYSPEPSTA. 

be resolutely diminished till breakfast is appreciated (Leared, 
1. c. p. 150). 

Special symptoms, common to various morbid states, re- 
quire special modes of treatment. Excess of acid is best 
neutralized by lime-water, magnesia, or alkaline remedies, se- 
lected according to the state of the patient's bowels ; and 
the gastric fermentation which is apt to be established may 
be checked by brandy and various aromatic spirits. Bicar- 
bonate of potash and nitrate of potash, in the proportion of 
eight parts of the former to one part of the latter, is useful 
in cases of habitual acidity : and all these antacid remedies 
should be taken about three or four hours after a meal. 
Pills containing from a quarter to half a minim of creasote, 
given with each meal, will counteract fetid eructations. It 
checks that fermentation in which acetic and carbonic acids 
are formed ; while conium and belladonna are the medicines 
which better than opium allay general nervous irritability. 
In cases of slow digestion, with deficient secretion of the 
gastric juice, the rules of treatment are, (t.) To let albu- 
minoid food be as liquid as possible. Eggs must be eaten 
when cooked short of coagulation of the albumen. (2.) To 
let the day's allowance of food be taken in small quantities 
at regular intervals. (3.) That by the administration of al- 
kalies the food may pass to the intestines, and be digested there 
rather than by the stomach. This latter mode of treatment 
by alkalies, reeommended by Chambers, is contrary to that 
recommended by Dr. Budd. Both are consistent with phy- 
siological facts, and the course to be followed must be de- 
termined by the nature of the case. Both gave large doses 
of bicarbonate of soda — 3 ii. dissolved in a pint of warm wa- 
ter — to counteract the excessive acidity, or to promote the 
passage of food to the intestines. The amount and kind of 
food taken is of importance to be attended to in cases of 
slow digestion. If a fair amount of exercise be taken, the 
following dietary, slightly modified from that proposed by 
Dr. Leared, will be found appropriate in such cases : 

Breakfast, (8 a. m.) 
Mutton Chop, or other ) Tea, or warm milk and 
Bread (stale), . 4 oz. -{ Meat (cooked) free >• water and sugar, or 
from fat and skin, 3 oz. ) other beverage, f pt. 

Luncheon, (i p. m.) 

No solids, such as Meat ) 

Bread (stale), . 2 oz. -j or Cheese. > Liquid, . . . i pt. 



DYSPEPSIA. II9 

Dinner, (5 or 6 p. m.) 

Bread (stale), . 3 oz ( Meat (cooked) free from ) Liquid, not more than 
Potatoes and other < fat and skin, . . 4 oz. ) half a pint, 
vegetables, . 4 oz. ( 

Tea or Supper (not sooner than three hours after dinner.) 

f Tea, or weak brandy 

Bread (stale), . 2 oz. i No SO ™ s > such as Meat I and water! ^rloast 
( ° r CheeSe> ( and water, to the ex- 

[_ tent of i pint. 

The quantity of wine or other fermented liquor, and also of 
animal diet, should be thus reduced till the disease subsides 
and the urine is healthy. Scaups, tea and coffee, drank, as 
they usually are, boiling hot, debilitate the coats of the stom- 
ach, tend to produce dyspepsia, and are abandoned by many 
persons from their so often exciting cardialgia. The best 
bread for the dyspeptic is the unfermented bread, baked by 
the process of the late Dr. Dauglish, entirely from wheaten 
flour of the best quality. It is known as " aerated bread," 
because carbonic acid gas is substituted for yeast. It is more 
easily digested than common household bread. Pastry and 
"sweets" must be strictly forbidden. They are " sweet in 
the mouth, but bitter in the belly." Forms of indigestion 
marked by excessive acidity and heartburn may be relieved 
by bicarbonate of soda, in doses of fifteen grains, combined 
with a few grains of nitre, taken two or three times a day. 
At the same time, free excretions from the liver and bowels 
must be sustained by occasional small doses of blue pill or 
podophyllin, combined with extract of colocynth and hen- 
bane, while exercise and diet are duly attended to. Weak- 
ened digestion from over-fatigue may be restored under the 
use of carbonate of ammonia, conjoined with compound tinc- 
ture of gentian, or with extract of gentian in the form of a 
pill. Extracts of nux vomica or strychnia are also valuable 
remedies. Half a grain of extract of nux vomica, half a grain 
of sulphate of iron, and four grains of compound colocynth 
pill, form a combination which, taken early in the morning, 
or one hour before dinner, generally induces gentle action of 
the bowels. (Leared). Compound rhubarb pill may be sub- 
stituted in place of the compound colocynth pill. Another 
useful ingredient in a dinner pill I find is ipecacuanha, to the 
extent of one grain, or half a grain in each, in cases of slow 
or torpid digestion. Indigestion from habitual drunkenness, 



120 ECLAMPSIA — -ECTHYMA. 

or where there is great irritability or sensitiveness of the 
stomach is best relieved by the pure bitter infusions, such as 
gentian, quassia, hops, and calumba, singly, or combined in a 
mixture, so that a dose may\be taken two or three times a day, 
an hour before each meal. Grave's tonic I have found espe- 
cially useful. It consists of the tinctures of quassia, calumba, 
compound gentian, cinchonia flava, of each an ounce, and 
from two to four drachms of the liquor morphiae hydrochlor- 
atis ; of this mixture a teaspoonful is to be taken one hour be- 
fore each meal. Quassia may generally be taken as a cold 
infusion, and is thus prescribed by Niemeyer ; " In the 
evening pour a cupful of cold water over a teaspoonful of 
quassia chips ; by the next morning a bitter infusion will 
have formed — to be taken fasting ;" or water may be poured 
into a bowl made of quassia-wood, sold for this purpose, and 
after standing over night in the bowl, the water is to be 
taken in the morning. Hop-bitter is most agreeably taken 
in the form of the many bitter ales, such as are brewed by 
Bass, Allsopps, Ind-Coope, Salt, and the genuine Bavarian 
beer, brewed all over Germany. Such ales must be got di- 
rect from trustworthy brewers who brew from hops, and 
where no injurious substitute is used instead of hops. For 
other reasons it is necessary to obtain the ale direct from the 
brewery. Once it passes into other hands, there is no guar- 
antee that some of the numerous processes for " stretching," 
and otherwise increasing the quantity, to the disadvantage 
of the consumer, will not be practiced. Of the extent of 
malt originally prepared by Trommer, as a genuine extract, 
containing the soluble constituents of the malt and of the 
bitter of the hop, Niemeyer speaks highly in the treatment 
of cases of "irritable ingestion," as having been almost the 
only nourishment the patients could take. Small doses of 
opium, or of morphia in an ammonia mixture, may be given 
at bedtime, so as to secure sleep at night, or Grave's tonic as 
above. In prescribing the mineral acids, the following gen- 
eral rule ought to be kept in mind, namely, that the influ- 
ence of sulphuric acid is astringent, while that of hydrochloric 
acid promotes digestion, and of nitric acid secretion (Dr. 
Bence Jones). 

Eclampsia. — See Convulsions. 

Ecthyma. — Definition. — An eruption of large round pus- 
tules, generally distinct, and seated upon a hard inflamed 
base. The pustules are succeeded by dark-colored scabs, 



ECZEMA. 121 

which leave superficial cicatrices behind them, or red stains? 
which disappear after a time. 

Treatment is chiefly by diluents, simple and emollient 
baths, and regulation of diet. Moderate exercise should be 
taken, combined with the use of alkaline or salt-water baths. 
Mild laxatives are beneficial, and spirits, wine, and beer are 
to be refrained from. The food should be as nourishing as 
can be digested. Tonics, such as quinine and iron, are also 
indicated. A stimulating lotion, composed of muriatic acid 
diluted with water, is of use to brush over the parts and pro- 
mote cicatrization. Specific treatment must be adopted 
when the disease is associated with syphilis or scabies. 

Eczema. — Definition. — An eruption characterized by — 
(i.) Infiltration of the skin ; (2.) exudation on its surface ; 
(3.) the formation of crusts ; (4.) itching. 

Treatment of eczema must be constitutional in the first in- 
stance ; and local applications suited to the nature of the 
part affected are to be carefully used. Derangements of the 
digestive organs must be especially rectified. If the tongue 
is loaded, the appetite bad, the liver torpid, as indicated by 
light clay-colored evacuations and costive bowels, small doses 
of grey power in combination with quinine are indicated. 
Dr. T. M. Anderson suggests the following : — 

P>. Sulphatis Quiniae, gr. xii.; Pulv. Rhei., gr. xxxvi.; 
Hydrarg. c. Creta, gr. xxx.; Sacchari Albi, 3 i.; misce, et di- 
vide in Pulv. xii. 

Two of these powders are to be taken daily by an adult ; 
but at any age the dose must be so adjusted that the patient 
has at least one full natural evacuation daily. If the patient 
is robust, but with the functions of the liver and bowels im- 
paired, occasional doses of calomel, alone or in combination 
with scammony, will stimulate the torpidity of the digestive 
organs ; and at the same time the cutaneous inflammation 
will diminish. If the patient is a full feeder, and will not be 
persuaded to live more sparingly, one drachm to two drachms 
of the sulphate of magnesia may be given twice daily, with a 
sixth to half a grain of tartar emetic added to each dose. 
The effect of this remedy will be to diminish desire for food, 
and at the same time keep the bowels freely open. If the 
patient is scrofulous, or debilitated from insufficient food, or 
food not nutritive enough, more nourishing food must be 
given, combined with tonics containing iron and cod-liver 
oil. Children a few months old, reduced to " skin and 
bone/' recover wonderfully under the influence of twenty 



122 ECZEMA. 

drops of the syrup of the iodide of iron in a teaspoonful ol 
cod-liver oil repeated three times daily, the dose of the oil 
being gradually increased to a tablespoonful (Anderson) 
Syrup of the phosphate of iron, or of the phosphates 
of iron, quinia, strychnia, should be alternated with 
the iodide of iron. The treatment must be steadily 
maintained for at least six weeks or two months. In severe 
cases the oil may be rubbed into the skin, in addition to giv- 
ing it internally. Cod-liver oil and iron preparations are 
almost equally serviceable to eczematous adults. When 
there is a difficulty of taking the oil in its pure state, the 
emulsion of it will often be found useful ; when the appetite 
is very deficient, a pure tonic, such as quinine and aromatic 
sulphuric acid, may be of service, as in the following : — 

fe. Sulphatis Quinise, gr. xvi. ; Acid Sulphurici Aromatici, 
3iv.; Syrupi Limonum % ss.; Infus. Cascarillae, ad 3 viii. ; 
misce, et cola per chartam. A table-spoonful to be taken 
three times a day half an hour before food. 

If the eczematous patients are robust and plethoric, the 
local abstraction of blood by leeches or scarification is often 
beneficial ; but in general the action of calomel purgation is 
sufficient to reduce the inflammatory action, combined with 
a regulated abstemious diet of mixed animal and vegetable 
food simply dressed. Dishes of pastry, pickles, spices, strong 
tea, and coffee, are particularly to be avoided ; while the use 
of wine, spirits, and malt liquors must be entirely suspended. 
If the patient has been in the habit of using stimulants, the 
eczema will be more difficult to subdue than if he had been 
an abstainer from these fluids. It is sometimes necessary to 
prescribe milk diet for a time, all animal food being pro- 
scribed. 

Of internal medicines, arsenic, sulphur, and the alkalies 
are especially useful (Startin, Anderson). Of Fowler's solu 
tion (the liquor arsenicalis of the Edinburgh Pharmacopoeia) 
an adult may commence with five minims thrice daily ; and 
at the end of a week the dose should be increased by one 
drop every second or third day, till the disease begins to 
yield, or the medicine to disagree (Anderson), " In order to 
secure the. virtues of arsenic as an alterative, it will be 
necessary to push the medicine to the full development of 
the phenomena which first indicate its peculiar action on the 
system. Arsenic as a remedy is too often suspended, or alto- 
gether abandoned, at the very moment its curative powers 
are coming into play. The earliest manifestation of its phy- 



ECZEMA. 123 

siological action is apt to be looked upon as its poisonous 
operation : and the 'patient declares that the medicine has 
disagreed with him. Forthwith the physician shares his 
fears ; the prescription is changed, and another case is added 
to the many in which arsenic is said to have failed after a 
fair trial of its efficacy" (Begbie, "Contributions to Practical 
Medicine", p. 270). Arsenical solutions should be given im- 
mediately after food ; and in persons whose digestive organs 
are weak, a tonic infusion, such as the infusion of cascarilla 
or gentian, is the best vehicle for its administration ; and 
a few drops of morphia may sometimes be added, as in the 
following : — 

R. Solut. Fowleri ; Solut. Muriatis Morphias, a a 3 ii- ; 
Syrupi Limonum, \ ss. ; Tinct. Cocci Cacti, 3 ss. ; Infus. 
Cascarilla, ad 3 xii. ; misce. A tablespoonful of this mixture 
to be taken thrice daily immediately after food. 

The liquor sodae arsenias, in doses of five to ten minims, 
is said to cure eczema with less gastric disturbance and with 
less irritability of the conjunctiva than the liquor arsenicalis. 
As the disease yields, the dose may be diminished ; but the 
use of the remedy should not be suspended till some time 
after the complete removal of the eruption. In the case of 
infants at the breast, arsenical solutions may be given to the 
mother; and mercury may be combined with the arsenic, as 
in Donovan's solution, of which ten minims may be given 
thrice daily. Mr. Hunt lays down certain conditions for the 
administration of arsenic; and amongst them he forbids its 
commencement while signs of active cutaneous inflammation 
are present. 

The use of the natural mineral waters which contain sul- 
phur is the best method of securing the full effects of the al- 
terative action of sulphur in chronic cases of eczema where 
there is an absence of inflammatory action. These waters 
are especially, Harrowgate and Moffat in this country; Aix, 
Bareges, St. Sauveur, Cauterets, on the Continent. Alkalies 
are most beneficial when the patient has been in the habit of 
taking stimulants; and when there is a tendency to acidity 
of the stomach, and to the deposit of lithates in the urine, or 
to gout, or to rheumatism, aqua potassae may be given, largely 
diluted with water, in doses of twenty minims three times 
a day. Dr. Anderson recommends sesquicarbonate of am- 
monia (now called the carbonate of ammonia in the British 
Pharmacopoeia), in doses gradually increasing from ten to 
thirty grains. If gout prevails, colchicum ought to be given 



124 ECZEMA. 

with the other remedies; and in rheumatism the acetate or 
bicarbonate of potash in half-drachm doses should be added 
to each dose. All these alkaline remedies should be largely 
diluted with water. For the relief of pain and procuring 
sleep in acute cases, opiates must be administered; and when 
they fail tincture of cannibis sativa, in doses of mxxv., has 
been found sometimes to procure sleep, or at all events com- 
parative ease (Christison). With regard to local treatment, 
the first point is to remove all sources of irritation, and es- 
pecially the crusts. A poultice composed of crumbs of bread 
and hot almond oil applied to the eruption at night will 
usually bring away the crusts in the morning. If they fail 
to be detached by this application, they must be again lubri- 
cated with fresh almond oil, and forcibly removed when they 
are thoroughly softened. If, after the crusts are removed, 
the surface is seen to be acutely inflamed, and if there is a 
burning heat in place of itching, local sedatives must be ap- 
plied. For this purpose Dr. Anderson recommends a cold 
potato-starch poultice, a small quantity of powder containing 
camphor being sprinkled over the inflamed surface before the 
poultice is applied. The camphor powder may be composed 
of the following ingredients: — 

IjL Camphorse, 3 ss. ; q. s. ; Pulv. Oxydi Zinci ; Pulv. 
Amyli, a a 3 iii- This powder must be kept in a stoppered 
bottle (Anderson). 

Instead of poultices, a mixture of powdered oxide of zinc 
and glycerine, in the proportion of half an ounce of the one 
to two ounces of the other, will be found to be a soothing 
application ; and to it a little camphor may also be added, as 
in the following : — 

I£. Camphorae, 3 i. ; Pulv. Oxydi Zinci, 3 ii. ; Glycerinae 
et Adipis Benzoati, a a 3 iv. ; Cochinillini, gr. i. ; Spt. Ros- 
mar., 3 i. ; vel 01. Rosar., mii. ; misce. This mixture must 
be stirred before using it, a thin layer being then rubbed over 
the inflamed part twice or thrice daily (Anderson). 

Carron oil (liniment aqua calcis) I have found a soothing 
remedy. When the disease passes into a chronic stage, as in- 
dicated by the disappearance of the burning heat and the 
supervention of itching, the local applications must vary with 
the condition of the parts. If there be much infiltration of 
the tissues, treatment by potash applications is the most ef- 
ficient (Hebra, Anderson). The more extensive the disease 
the weaker the solution ought to be for application over a 
large surface. If the infiltration is slight, common potash 



ECZEMA. I25 

soap (soft soap, black soap, sapo mollis, sapo viridis), or a 
solution of one part of it in two of boiling water, a little oil 
of rosemary or citronella being used to conceal the odor, may 
be used. A piece of flannel dipped in this liniment should 
be rubbed as firmly as possible over the affected parts night 
and morning, the solution being allowed to dry upon them. 
It should, however, be washed off after each application. If 
the patient can bear it, a piece of flannel, saturated with the 
solution, may be left in contact with the part all night. An- 
other method of treatment is to paint over the eruption night 
and morning with a large brush, charged with the aqua po- 
tassse of the Edinburgh Pharmacopoeia, its irritant action 
being neutralized by means of cold water when the smarting 
becomes excessive. A solution of potassa fusa may also be 
employed of various strengths. If the case be mild, two 
grains to an ounce of water; if more severe, then five, ten, 
twenty, thirty, or even more grains to the ounce of water 
may be used. But all these stronger solutions must be washed 
off very speedily, and they ought not to be employed more 
than once daily. Such remedies the physician ought to ap- 
ply himself, and not entrust the control of their action to the 
patient. As infiltration subsides, the solution ought to be 
gradually diluted; and great caution is necessary in using 
such local applications upon infants, delicate females, and old 
Dr infirm persons. The affected parts should be bathed re- 
peatedly during the day in cold water, during the use of po- 
tash applications. The cold douche may be employed where 
it is practicable. If the itching is very intolerable, prussic 
acid may be mingled with the potash applications, as in the 
following: — 

3- Potassae Fusae, gr x.; Acid Hydrocyan. Dil. (Ed. Ph.) 
3 ss. ; Aq. Rosarum, 3 ii. ; misce. A little of this solution is 
to be rubbed firmly over the eruption night and morning, and 
at any time when the itching sensation is severe. 

If there is a tendency to the formation of fissures, which 
are apt to result from the use of potash, cod-liver oil, glycer- 
ine, or carron oil should be applied to the parts every night. 
Glycerine of aloes is also recommended as a healing agent 
by M. Chausit and Dr. Waring. It is prepared by evaporat- 
ing four to eight parts of the tincture of aloes, and incorpo- 
rating the residuum with thirty parts of glycerine. Tarry ap- 
plications are of great value in the local treatment of the de- 
clining stages, when infiltration and itching are subdued. 
Common tar (pix liquida) or oil of cade (oleum cadini, as 



126 ELEPHANTIASIS GR^CORUM. 

manufactured at Aix-la-Chapelle) should be rubbed firmly 
over the eruption by means of a flannel cloth, and allowed to 
dry upon it. It should be applied thrice daily, and washed 
off with soft soap or petroleum soap. Dr. Anderson recom- 
mends that common tar should be combined with one of the 
potash solutions — for example, a mixture of equal parts of 
common tar, methylated spirit, and soft soap, used as above 
directed, will be found useful, or the following preparation, 
as less offensive: — 

fy. Saponis Mollis, Spt. Rectincati, Olei Cadini, a a 3i.; 
Olei Lavandulae, 3 iss. ; misce. A little quantity is to be 
firmly rubbed over the eruption night and morning; and it 
must be washed off before each reapplication. 

Of mercurial applications the citrine ointment (Ung.-hyd. 
nit.) is the best, or the ointment of the iodide of mercury. 
They may be used of their full strength, or diluted with lard, 
according to the indications of the case, care being taken 
that mercurialism is not induced. When eczema has reached 
the dry stage, Mr. Milton regards the dilute o'intment of the 
nitrate of mercury as the most effectual remedy we possess. 
In the itching of pruritus — pruritus scroti and prurigo pudendi 
muliebris — especially the prurigo senilis, the dilute ointment 
is highly spoken of by Dr. Bowling, United States, and by 
Dr. Balmanno Squire in this country, as one of the best rem- 
edies for subduing the irritation and itchiness. Dr. Bowling 
advises that the parts be first sponged with vinegar or lemon- 
juice previous to the application of the ointment; and states 
that for fifteen years he has not failed to effect a permanent 
cure {Med. Times, June 6, t868). In using ointments, a 
small quantity should be melted on the finger, and rubbed 
firmly into the affected part. None should be allowed to lie 
undissolved upon the skin; and the part should always be 
cleansed with soap and water before reapplication. Epila- 
tion should be resorted to in cases of eczema of the hairy 
parts of the face. In very mild attacks, or with a view to 
prevent the recurrence of the disease, the skin may be washed 
occasionally with soft soap and water. Hendrie's " Dispen- 
sary Petroleum Soap " is recommended by Dr. Anderson, to 
whose admirable lectures on "Eczema," in the Medical 
Ti?nes and Gazette for May, June and July, 1863, (since pub- 
lished in a separate volume), the reader is referred for more 
detailed information. 

Elephantiasis Graecorum— See Leprosw True. 



EMPHYSEMA ENCEPHALITIS AND MYELITIS. I27 

Emphysema — See Lungs, Emphysema of. 

Encephalitis and Myelitis. — Definition. — Inflammation 
of the brain and spinal cord substance, with or without im- 
plication of the membranes, usually partial. 

Treatment. — i. Encephalitis. — So soon as there are any cir- 
cumstances which may lead to " head symptoms " after in- 
jury, it is well to commence treatment at once with local 
antiphlogistics, leeches, and evaporating lotions, such as 
muriate of ammonia in solution with vinegar, applied by 
tloths, which are to be frequently changed. The patient 
inust be made to observe a rigidly abstemious regimen, and 
test with the head elevated above the shoulders. Purgation 
is to be instituted by means of watery evacuants, and the 
same general treatment is to be adopted as in meningitis. 

2. Myelitis. — In classing ramollissement of the cord with 
inflammation, it might appear to infer that the treatment 
should be strictly antiphlogistic. It may be laid down as a 
general rule, however, that bleeding ought not to be had re- 
course to after palsy has occurred. Previous to that symp- 
tom it may be admissible; and it maybe stated generally, 
that so long as the affected muscles are convulsed, rigid, and 
irritable, the use of antiphlogistics and counter-irritants may 
be indicated; but when the means calculated to subdue ex- 
citation have failed to arrest the further progress of the dis- 
ease, and paralysis supervenes, stimulants are the only reme- 
dies which have the power of restoring to functional activity 
those nerve-cells and conducting fibres which are not irre- 
trievably destroyed (Meryon). The chances of saving the 
patient by other antiphlogistic remedies mainly rest on act- 
ing on the alimentary canal so as to produce three or four 
motions in the twenty-four hours, and thus create such a de- 
rivation as in some degree to relieve the parts. The greater 
number of patients that recover are restored by these means. 
The particular purgative is not perhaps important; but as 
the neutral salts act not only on the intestines, but also on 
the bladder, that class of remedies is generally preferred. 

With respect to local counter-irritants, as blisters, moxas, 
or setons, little favorable can be said, unless they are em- 
ployed previous to paralysis, as the tendency to gangrene 
renders their application of doubtful utility. When had re- 
course to, hoAvever, it will be found better to apply them 
above the seat of the disease than immediately over it, the 
greater vitality of the superior parts giving more assurance 



128 ENCEPHALITIS AND MYELITIS. 

of the disposition of the wounds to heal. Of all stimulant 
remedies, electricity and strychnine are the most potent and 
the best. Secale cornutum has been recommended as a 
remedy possessing the same power as strychnine (Barbier, 
Payen, Meryon). When there is no great pressure beyond 
that which simple congestion produces, nor actual disorgan- 
ization of the spinal cord, the remedial power of secale 
cornutum is said to be very great. It seems especially to 
resuscitate the muscular contractility of the rectum and 
bladder, the pelvic viscera generally (Guersant, Trousseau, 
Brown-Sequard, Meryon). The ergot of rye may be given 
in the forms and doses as follows: — (i.) Ergot, 5 to 10 
grains, infused in boiling water, three times a day; (2.) 
Ethereal tincture (not now in the pharmacopoeia), in doses 
of from ten to twenty drops, twice or three times a day; (3.) 
Extractum ergotae liquidum, 15 to 30 minims; (4.) Infusum 
ergotae, made fresh on each occasion, 1 to 2 ounces; (5.) 
Tincturse ergotae, 15 to 60 minims. It does not relieve the 
reflex convulsions, which are sometimes alleviated by 
Purssic acid, digitalis, belladonna (Meryon, chlorodyne 
or chlor-morphine. [Conflicting statements exist in text- 
books on Materia Medica as to the best form of ergot 
for internal administration. 1. Ergot contains one-third 
of its original weight of oil, got out by percolation with 
ether (Squire). 2. It contains a large quantity of fixed oil, 
about 75 per cent. (Garrod). 3, It contains 25 to 28 per 
cent, of fixed oil (Stille and Maish). Ergot preserves its 
virtues not much over a year (Stille and Maish). The active 
principle is a body somewhat resembling gelatine, formed 
from the gluten of rye ovary, and readily changed by the in- 
fluence of chemical agents (Bucheim). A number of non- 
crystallizable compounds, possessing more or less activity, 
have been isolated from ergot, the most important being 
sclerotic acid (to the amount of 4 and 4^ per cent.), the 
other, scleromucin, to the extent of 2 to 3 per cent. This 
multiplicity of uncrystallizable principles may explain why 
preparations possessing some activity may be obtained from 
very different processes — e.g., Wiggers' ergotine, obtained in 
1830, is soluble in alcohol, but insoluble in water and ether, 
and is said to have poisonous properties. Bon jean's Ergotine 
(Germ, pharmacop., as " Extr. Secalis Cornuti ") is a con- 
centrated aqueous infusion, precipitated by half its weight 
of alcohol, and the clear filtrate evaporated. Wenzell (1864) 
proved the presence of two alkaloids (ecbolina and ergo- 



ENCEPHALITIS AND MYELITIS. I 29 

tina). They exist in combination with ergotic acid. These* 
have been since shown to be identical, and to possess no de- 
cided physiological action (Dragendorff and Blumberg). In 
1875 Tannet isolated another alkaloid, ergotinina, from the 
fixed oil of ergot prepared by ether, by agitating it with 
acidulated water.. Fresh ergot yields .12 per cent, of ergo- 
tinina, which is crystalline, but soon becomes resinous. As 
regards the properties of the oil extracted from ergot by 
maceration with ether, Stille and Maish write that " it dis- 
plays even greater energy in producing the same symptoms, 
and in addition other symptoms (which are specified), than 
does ergot itself. The effects continue for several days:" but 
they add that " the oil exhibits no influence upon the gravid 
uterus, but the residual ergot from which it had been ex- 
tracted seems to possess the ecbolic power of the drug unim- 
paired " (The National Dispensatory, p. 545). It does not 
appear, therefore, that we are warranted in rejecting the 
ethereal tincture of ergot as an inert preparation, as Mr. 
Squire has represented it to be (Compan. to Pharg., 1871), 
It may still be the best form of remedy for some cases, al- 
though it has become obsolete as a pharmaceutical prepar- 
ation in our pharmacopoeia; while the residual ergot, pos- 
sessing ecbolic powers, may be also useful for other pur- 
poses. Besides, Mr. Squire states that in the directions for 
preparing the extractum ergotse liquidum (doubtless a valu- 
able and energetic preparation when properly made from 
fresh ergot), the ether ordered is not sufficient to extract all 
the oil. The quantity, he states, ought to be doubled. So 
that this energetic preparation, if prepared as directed in 
our British Pharmacopoeia, still contains half the oil left by 
the insufficient quantity of ether which is used, so that the 
whole of the oil is nor now rejected in preparing the ex- 
tractum ergotse liquidum. A writer in Medical Times and 
Gazette (Oct. 16, 1875), under the signature of " Eyes 
Right," has described how " teachers differ " on matters of 
fact, and gives the teachings of Squire, Aitken, and Garrod, 
on " Ergot " as an example. But from what I have quoted 
from the most recent teachings of Stille and Maish, I do not 
find we are justified in excluding the Ethereal tincture of 
ergot as an inert preparation.] 

After the local pain in the back has been subdued (by the 
regular and repeated application of two or three leeches to 
the painful part, followed by a large warm poultice over the 
whole length of the spine, and a belladonna plaster of equal 



I30 ENDOCARDITIS. 

length to follow it or an occasional blister on each side of 
the spine, together with mild, warm purgatives, if necessary). 
Dr. Meryon has found no remedy so effectual as strychnia, 
in the dose of one-twentieth of a grain, repeated more or 
less frequently (twice or three times a day), according to 
the evidence of its action It may be combined advantage- 
ously with ipecacuanha in cases where the intestinal mucus 
seems deficient The absence of pain and of spasmodic 
muscular contraction necessitates great caution in deter- 
mining the precise moment when the spinal cord is likely to 
be benefited by the energetic excitement of strychnia. The 
internal administration of this remedy ought, therefore, to be 
always preceded by its external use, together with other 
stimulants, in the form of embrocations over the spine, when 
the stage of excitation has been subdued. In cases with a 
history of syphilis, and where there: may be some reason to 
believe that hardening or induration of the cord or its mem- 
branes has taken place, the iodide of potassium may relieve 
the early phenomena, and by the aid of setons the progress 
of the disease may be held in abeyance, so long as the dis- 
charge is maintained from the seton. 

When disorganization of the spinal cord has become an ac- 
complished fact, the disease is incurable, but yet the exigen- 
cies of the patient are not the less pressing on the careful 
attention of the physician, and in nothing more so than 
in the protection which is called for against bedsores, 
which will sometimes occur in spite of the greatest care 
(Meryon. 

Electricity, after the activity of inflammation has been 
subdued, is a therapeutic agent of great value; and the con- 
tinuous current of galvanic electricity seems to be just as 
efficacious as the induction or intermittent current. But 
whether galvanism or electro-magnetism be employed, no 
high degree of tension is required for the restoration of mus- 
cular power; on the contrary, Dr. Meryon justly believes 
that the favorable course of many a case has been retarded 
by the employment of strong currents. Dr. Althaus, also, is 
in favor of weak currents. 

Endocarditis. — Definition. — An inflammation of the 
lining serous membrane of the heart, covering the valves and 
lining the chambers of that organ. 

Treatment. — No defined line of treatment can be laid 
down suitable for all cases; because the circumstances under 



ENTERIC FEVER. 131 

which endocarditis occurs are extremely varied. What has 
been written relative to pericarditis applies equally to endo- 
carditis; but the management of cases in which the patients 
suffer from valvular lesions and their immediate conse- 
quences demands the adoption of various lines of treatment. 
Stimulants are generally called for in large quantities; and 
digitalis also may be necessary if the action of the heart is 
weak and failing. When endocarditis seems lapsing into 
the chronic stage, the use of iodide of potassium and liquor 
potassse, combined with bitter tonics and abundant nutri- 
ment, are to be recommended. Alkalies and carbonate of 
ammonia are to be given with free stimulation by alcoholics 
in cases of obstruction from blood coagulation in the cavi- 
ties of the heart. Cases of malignant, infective, or ulcerative 
endocarditis (attended with fever and pyaemic symptoms in 
which retinal haemorrhages are almost invariable), are to be 
treated in the same way as cases of septicaemia. They con- 
stitute the diphtheritic endocarditis of the Germans, some 
septic source poisoning the blood 

Enteric EeTer. — Definition. — A continued specific fever, 
having an incubation-period of about two weeks, with an 
eruption on the skin of isolated, elevated, rose-colored spots, 
chiefly on the abdomen, appearing generally from the seventh 
to the fourteenth day, occurring in crops, each spot continu- 
ing visible about three days and vanishing on pressure. 
Languor and feebleness are prominent from the first, attended 
by headache, abdominal pains, and (early) by spontaneous 
diarrhoea; but absolute prostration does not come on till late, 
the patient rarely taking to bed before the seventh or tenth 
day. With the advance of the disease the diarrhoea increases, 
the discharges being for the most part liquid, copious, of a 
bright yellow color, devoid of mucus, occasionally containing 
altered blood. In reaction the discharges are alkaline, and 
contain a large proportion of soluble salts with some albumen. 
The fever may terminate favorably by a gradual restoration 
to health during the fourth week. The average duration of 
the illness is about twenty-three days. Death in the majority 
of fatal cases occurs towards the end of the third week. 
There' are special symptoms sometimes associated with the 
characteristic lesion of this fever — namely, fulness, reso- 
nance, and tenderness of the abdomen; more or less tympa- 
nites, with gurgling in the iliac fossae; and increased splenic 
dulness. The specific lesions are enlargement of the spleen 
and the mesenteric glands, with enlargement, ulceration, or 



I32 ENTERIC FEVER. 

sloughing of the glands of Peyer and the minute solitary 
glands of the small, and sometimes also of the large, intestine. 

Treatment and Management of Eiiteric Fever. — The 
management of a case of enteric fever resolves itself 
into two lines of practice, embracing, — (1.) Preventive mea- 
sures. (2.) Therapeutic Treatment. 

(1). Preventive Measures, or Measures for Checking the 
Spread of Typhoid Fever. — Whatever maybe the view theo- 
retically adopted regarding either the origin or the propagation 
of typhoid fever, it is satisfactory to know that, practically, 
medical officers can employ preventive measures which (to use 
the words of the late Dr. Lankester) " will cover the issues 
of both theories." If these are universally carried into ef- 
fect, it is not too much to expect that this fever might per- 
haps soon become extinct. At all events, with the facts be- 
sore us, it is unwarrantable to permit the great bulk of what 
escapes from the diseased intestine of typhoid fever patients 
to be let loose upon society, into the cesspool or sewer, or 
on the dung-heaps, in full possession of all their deadly power, 
without being first destroyed in the way to be presently re- 
commended. "The grand fact is clear," writes Dr. Parkes 
" that the occurrence of typhoid fever points unequivocally 
to defective removal of excreta, and that it is a disease 
altogether and easily preventible." Typhoid fever ought 
therefore soon to disappear from every return of disease, 
whethei in military or in •civil life. The measures about to 
be specified have been made public mainly through the 
writings of Dr. William Budd; and, provided they are 
thoroughly and efficiently carried out, it is believed that the 
recurrence of typhoid fever may be entirely prevented. To 
enable us to judge of the extent of the infection to be des- 
troyed, there are two elements to be taken into account, — 
First, The amount and duration of the intestinal discharge 
in each case; and, Second, The number of cases actually 
occurring. With regard to the first, Louis has found 
that the average duration of the alvine flux in cases of ty- 
phoid fever is fifteen days in mild cases and twenty-six days 
in severe cases. With regard to the second point — namely, 
the number of cases occurring — the Reports of the Regis- 
trar-General show that at least 100,000 to 150,000 cases of 
typhoid fever occur annually in England alone. In other 
words " every year in England more than 100,000 human 
intestines, diseased in the way already described, continue 
each, for the space of a fortnight or thereabouts, to discharge 



ENTERIC FEVER. 133 

upon the ground floods of liquids charged with matters on 
which the specific-poison of a communicable disease has set 
its most specific mark " (Budd). 

The measures recommended for preventing the spread of 
this fever are founded on the power of chemical agents to 
destroy absolutely the material which contains or carries the 
specific virus of such communicable diseases. Assuming it, 
therefore, to be certain that the intestinal discharges in ty- 
phoid fever are the media of propagation of the disease, it is 
no less certain that, by subjecting the discharges on their 
issue from the body to the action of powerful decomposing 
chemical agents, they may be entirely destroyed or deprived 
of their specfic virus. The following details of procedure 
are suggested : — (a) All discharges from the fever patient 
should be received on their issue from* the body into vessels 
containing a concentrated solution of chloride of zinc, (b) 
Two ounces of a caustic solution of chloride of zinc should 
be put in the night-stool on each occasion before it is used 
by the fever patient. (V.) All tainted bed or body linen 
should, immediately on its removal, be placed in water 
strongly impregnated with the same agent, (d.) The water- 
closet should be flooded several times a day with a strong solu- 
tion of chloride of zinc, or of sulphate of iron or carbolic acid; 
and some chloride of lime should be also placed there, to 
serve as a source of chlorine in the gaseous form. (<?.) So 
long as fever lasts, the water-closet should be used exclu- 
sively as a receptacle for the discharges from the sick after 
being thus disinfected. (/.) Pieces of rag should be used 
for wiping the remains of all discharges from the patient's 
body, and burned immediately after use. The Privy Coun- 
cil have now made the principle of this method an integral 
part of their " General Memorandum on proceedings advis- 
able to be taken in places attacked or threatened by epide- 
mic disease." 

(2.) Therapeutic Treatment of Enteric or Typhoid Fever 
aims at reducing temperature and subduing vascular excite- 
ment, if these be in excess; restraining and moderating, but 
not actually suppressing or altogether checking the diarrhoea; 
stimulating and restoring the nervous system; obtaining a 
free excretion from the kidneys; and bringing about a gra- 
dual elimination of the morbid growth from the intestinal 
glands with as little ulceration as possible. To accomplish 
the first of these indications the use of digitalis has been es- 
pecially recommended by Wunderlich. He considers that 



134 ENTERIC FEVER. 

it decidedly mitigates the febrile symptoms which are pres- 
ent in severe cases at the time when the ulcers begin to heal, 
and which often impede or prevent recovery. He advocates 
its use in the severe forms of the fever only, especially at a 
time when most danger is to be apprehended from the vio- 
lence of the fever in the second week, when the evening 
temperature is at its highest (105 to 108 Fahr.), and when 
the remissions in the morning are slight; when the pulse is 
frequent, no to 120 or more. In mild cases it is superflu- 
ous. He finds that in the form of infusion it is easily ab- 
sorbed by the intestines of patients suffering from fever; 
and, if given in a suitable dose, has most marked effects in 
subduing the rate of pulsation, and in reducing animal heat. 
Large doses of the infusion should be given without inter- 
ruption until the full effect has been obtained, — 

An infusion of fifteen or twenty grains of digitalis in eight 
or ten ounces of boiling distilled water may be consumed in 
twenty-four hours by adult patients. 

It acts more rapidly on animal temperature than on the 
heart. For the first few days after its use trie decrease of 
temperature is rather slight, but may afterwards become 
considerable; and after the temperature has been much 
diminished and again rises, it never attains its former ex- 
cessive height. The full effects of the medicine are known 
to be brought about if the temperature is reduced 2 or 3 
Fahr. in the evening; and the action of the remedy does not 
continue beyond one day after its use has been discontinued. 
The diminution of the pulse is slight at first, and 
occurs in some cases on the second day after the remedy, 
but mostly on the third day, or even later; and on the fourth 
or fifth day after the medicine has been commenced the 
rate of pulsation may be diminished by thirty to forty or 
fifty beats within from twelve to thirty-six bours. The pulse 
may continue to fall even below its normal velocity, and this 
reduction of pulsation may last for several weeks in succes- 
sion. If the velocity of the pulse should decrease rapidly, 
the use of digitalis must be discontinued at once ("Arch, 
der Heilk., 1862, p. 116). Cold and tepid sponging, or the 
cold affusion, are remedies deserving of further trial for 
reducing the pulse and temperature. The oppressive head- 
ache may be greatly relieved by cold to the head ; and in 
all severe cases the hair should be shaved off. 

To restrain excessive diarrhoea, lime water mixed with milk 
in equal parts and taken as a drink, is found to be beneficial, 



ENTERIC FEVER. I35 

agreeable, refreshing, and nourishing. It is clear that the 
diarrhoea ought not to be altogether checked. Professor 
Gairdner, of Glasgow, is in favor of the French practice of 
giving saline laxatives rather than astringents ; also of the 
diligent use of enemata to unload the bowels from below, 
where anything like abdominal distension has occurred. 
These enemata may be simply of warm water, to which a 
little aniseed is added ; or the asafcetida enema may be 
given. Of the propriety of restraining excessive diarrhoea, 
there can be no question. Dr. Huss, of Stockholm, is of 
opinion that the diarrhoea during the first stage ought not 
to be arrested, but abated and mitigated — only if excessive. 
If it is suddenly arrested, meteorism is produced ; and pains 
in the intestines or vomiting may supervene, with cerebral 
symptoms. The febrile phenomena are then increased. 
The diarrhoea is too copious or excessive if the evacuations 
exceed four or five a day, being of considerable quantity, 
and fluid. Such evacuations weaken the patient rapidly, 
and should be mitigated by mucilaginous drinks, such as 
rice-water, infusion of linseed, decoction of althaea officinalis 
or ipecacuanha in small and repeated doses. This latter reme- 
dy retards the peristaltic action of the intestines, and lessens 
the secretion from the mucous membrane. The dose must 
be regulated so as to avoid vomiting : and the feeling of 
nausea which is apt to follow the first dose soon disappears 
with continued use. 

On the other hand, the highest authorities write : " Re- 
strain diarrhoea and haemorrhage in typhoid fever, and when 
you have fairly locked up the bowels, keep them so. Pa- 
tients will go for four or six days, or even longer, without 
suffering inconvenience from this state of constipation." 
(Murchison, Todd). The benefits to be derived from the 
mineral acids — hydrochloric and sulphuric especially — are 
highly spoken of. From fifteen to thirty minims of the dilute 
acids may be given every three or four hours ; and with 
each dose half a grain of quinine, as in the following pre- 
scription for an adult : 

5 Acid.Sulph. dil., vel Acid.Hydrochlor. dil., m xx. ad.xxx. 

Quiniae Sulph. gr. ^ ad gr. i. 

Syrup Aurantii, 3 ss. 

Aquae Carui, | i. 
Fiat haustus, 3a vel 4a hora sumendus. 

If there be more than two motions in the twenty-four 



I$6 ENTERIC FEVER* 

hours, with marked prostration, astringents should be had 
recourse to (Mtirchison). A starch enema, containing from 
ten to twenty drops of laudanum, should be administered 
towards evening, and recourse may also be had to the follow- 
ing draught : 

r* Acid. Sulph. Aromat., m xxx. 

Liq. Opii. Sedativ. (Battley), m iii. 
Aq. Menth. Pip. |i.; miscc. 

Fiat haustus, 4ta vel 6ta quaque hora sumendus. 

If the mineral acids are not tolerated by the stomach, 
acetate of lead is worthy of trial, in doses of two or three 
grains in solution every four or six hours, with or without 
an eighth of a grain of morphia (Murchison). Alum dis- 
solved in gum, to the amount of twenty-four grains in a day, 
which may be increased to one drachm, is best given in the 
form of alum whey, prepared by adding one drachm of alum 
to a pint of boiling milk, and then straining. Two ounces 
may be given after each motion of the bowels (Fouquier, 
Murchison). A seidlitz powder may sometimes check' 
excessive diarrhoea, by altering the secretions, and is espec- 
ially beneficial if there be much meteorism (Trousseau, 
Murchison). 

The question, therefore, of checking excessive or encour- 
aging moderate diarrhoea, is one which requires the careful 
study of each particular case ; and my experience in the 
treatment of typhoid fever leads me to recommend rather 
the restraining of excessive diarrhoea than either encourag- 
ing the action of the bowels or locking them up for days. 
The French practice of giving saline laxatives is not a safe 
one , and if the action of the bowels is deemed desirable, 
enemata will be found sufficient. Nitrate of silver, in doses 
of one to three grains, made into a pill, and taken every six 
or eight hours, or sulphate of copper, in doses of a quarter 
of a grain similarly given, are remedies most useful in the 
diarrhoea connected with atonic ulcers, after the fourth week 
of the disease (Bell, Murchison). If meteorism or tympanites 
prevails from the accumulation of air in the colon, it may 
sometimes be relieved by the passage of a long flexible tube 
by the anus, as far up the colon as it can be made to go 
easily. With regard to stimulation it is not decided how far 
alcohol is beneficial. The fever eventually is attended with 
much exhaustion, and is often protracted, yet typhoid fever 
does not seem to bear stimulation so well as typhus. The 
tendency to prostration is the only indication for its use ; 



ENTERIC FEVER. 137 

but stimulation must not be persevered in if the pulse is 
quickened by its use, the hectic flush made more manifest, 
the tongue made drier, or if delirium supervene. Food and 
sustenance are the real preventives of delirium, and the best 
stimulants when necessary. With regard to the maintenance 
of free action from the kidneys, it is to be observed that so 
long as the excretion of urea and uric acid is abundant, no 
diuretics are necessary ; but whenever the amount of the 
solids falls greatly (which can be known at once with suffi- 
cient accuracy by a comparison of the urine passed in twenty- 
four hours with the specific gravity), means must be taken 
at once to increase, if possible, the urinary elimination. The 
warm bath, with repeated small doses of the alkaline car- 
bonates, or of the nitrate or bitartrate of potash, will often 
effect an increased elimination (Parkes, 1. c.) 

To accomplish the last indication — namely, to influence 
the elimination from the intestinal glands, by direct local 
action on the intestinal membrane — Wunderlich and Parkes 
especially advocate the use of calomel, if it can be given be- 
fore the ninth or tenth day. The late Dr. Anthony Todd 
Thomson used to give it ; and, from the observation of many 
cases under the care of this physician, as well as from his 
own experience, Dr. Parkes considers that calomel is a med- 
icine to be strongly recommended in typhoid fever. But it 
must not be given later than the tenth or eleventh day, and 
at no time in large doses. In the great majority of cases 
where it can be given during the first week and before the 
occurrence of much diarrhoea, the course of the disease is 
rendered milder and shorter. Such is now the recorded ex- 
perience of Wunderlich, Niemeyer, Parkes, and Wood. One 
or two grains twice a day is enough, although Wunderlich 
gives one to five grains twice daily ; but five grains is con- 
sidered by Dr. Parkes to be too large a dose. Dr. Wood of 
Philadelphia bears testimony to the benefit to be derived 
from mercury about the seventh or ninth day of the fever. 
He believes " it tends in some degree to arrest the progress 
of the disease in the glands of Peyer, and to promote resolu- 
tion of the inflamed patches. He prefers minute doses of 
the blue pill mass — a grain every two hours — till the mouth 
is slightly affected, associated with small doses of ipecacuan- 
ha, when the stomach is not irritable. The beneficial effect 
of this combination is shown by the tongue becoming moist, 
the skin relaxed, and the symptoms generally being amelior- 
ated. Twelve grains of blue pill mass are to be combined 



I38 ENTERIC FEVER. 

with two grains of ipecacuanha powder, and with two grains 
of opium powder. The whole is to be divided into twelve 
pills, one of which may be taken every hour, or every hour 
and a half, or every two hours (Wood, " Practice of Medi- 
cine," Vol, I., p. 345, 4th edition). Calomel is, however, 
contra-indicated if the diarrhoea is excessive, or if there 
should be excessive pains in the bowels, with early and vio- 
lent meteorism. It is also not proper to be given if the con- 
dition of the patient is anaemic, or if there is a decided hae- 
morrhagic diathesis. It is most useful as a restorative of the 
intestinal functions in cases where the tongue is dry and 
coated, where thirst is absent, and when the urine is cloudy 
and of low specific gravity. If the first dose is vomited, the 
administration must be repeated. Calomel has no direct ef- 
fect on the pulsation or respiration, nor on the cerebral func- 
tions ; but its beneficial influence is very decidedly appreci- 
able by the modifications of temperature which it induces. 
No general rules can be laid down to guide the treatment 
of the intercurrent phenomena or accidents of the disease. 
Combinations of remedies must be adapted to correct the 
several functions which may be simultaneously deranged, so 
that treatment must be varied according to the functions 
mainly implicated or suspended, and to the degree of their 
affection. Abdominal pains and meteorism may be relieved 
by mustard poultices, or turpentine stupes may be applied, 
followed by simple hot water fomentations. After these re- 
medies have been used, water compresses over the abdomen 
tend to lessen the tension and the gurgling in the intestines, 
and to diminish the tenderness on pressure. They counter- 
act the inclination to meteorism, and lessen excessive diar- 
rhoea. Dr. Huss believes also that the ulcerations in the il- 
eum are prevented from spreading, and that perforations of 
the intestine have been of much rarer occurrence since he 
commenced to use these compresses. The compress, after 
being soaked in warm, but not hot water, is well wrung, and 
applied so as to cover the whole abdomen ; and it must be 
changed two or three times a day, according to its tendency 
to dry. The compress is composed of four to eight double 
folds of coarse linen, and is to be laid over the whole abdo- 
men, and afterwards overlaid with a cover of oiled skin or 
india-rubber stuff, to prevent too rapid evaporation. The 
compress should fit as closely as possible, and care must be 
taken that it be not displaced, otherwise air enters between 
the skin and the compress, so that cold, instead of a moist 



ENTERIC FEVER. I39 

heat, is produced. These compresses may remain untouched 
as long as they are moist and warm ; and they may be em- 
ployed on the chest as well as on the abdomen should capil- 
lary catarrh or pneumonia supervene. 

Haemorrhage from the bowels, partly fluid and partly in 
clots, evacuated with the stools, is a symptom of grave import; 
and one urgent aim of treatment is to arrest the bleeding. 
Huss found the sugar of lead most serviceable, administered 
by the mouth, and also by clysters. By the mouth, two grains 
may be. given every half-hour, and even every quarter of an 
hour ; and it is best given dissolved. Twenty-four grains 
of crystallized acetate of lead, being dissolved in one drachm 
of dilute acetic acid, to which six ounces of distilled water 
is added, —a table-spoonful of this solution may be given 
every half-hour. At the same time a clyster may be admin- 
istered, composed as follows : — Ten to fifteen grains of ace- 
tate of lead are to be dissolved in four ounces of distilled 
water (warm), to which twenty to thirty drops of tincture of 
opium may be added ; and the administration of such a cly- 
ster may be repeated in four or six hours if required. Pieces 
of ice may also be swallowed now and then ; and even 
crushed ice may be applied, inclosed in a bladder, over the 
abdomen. If bleeding from the nose is not arrested by the 
use of vinegar and cold water injected up the nostril"?, nor by 
the use of cold water compresses applied to the nose, plug- 
ging by the posterior nares must be had recourse to. Turpen- 
tine is a most valuable remedy in haemorrhages, and in the 
stage of ulceration. It was originally recommended by Dr. 
Graves, and is highly spoken of by Drs. Huss, Wood, and 
Murchison. It may be given in all cases where the tongue 
is dry, and when " instead of cleaning gradually from the 
edges and tip, it often parts with its fur quickly, and in large 
flakes — generally, first, from the middle or back part of the 
surface, which is smooth and glossy, as if deprived of its pa- 
pillae. There is also generally an increase of the tympanites, 
and the ulceration of the ileum seems to be attended with 
great dryness of the tongue." Under these circumstances 
Dr. Wood gives the oil of turpentine in doses of five to twen- 
ty drops every hour, or every two hours. It is best admin- 
istered in an emulsion with gum-arabic, loaf sugar, water 
(Wood) ; or in an emulsion with the yolk of an egg and honey 
or mucilage (Huss). Amelioration of the symptoms maybe 
observed in twenty-four or forty-eight hours — the tongue 
becoming more moist, and covered with a white fur — disten- 



T40 ENTERIC FEVER. 

sion of the abdomen ceases to progress, and after a time di- 
minishes. The use of the oil should be continued under 
these circumstances ; but the dose should be gradually di- 
minished. 

Tonics and stimulants may be absolutely essential on ac- 
count of debility attending the advanced stage of the disease, 
generally about the third week. When the pulse is slow and 
feeble, the skin cool, the tongue and teeth encrusted with 
dark sordes, at an advanced period of the fever, then stimu- 
lants are obviously necessary. But even when the pulse is 
teeble, but yet frequent, and the skin hot, stimulants are even 
then known to be of service. It is necesssry to administer 
them in every case with great caution, and to watch the 
effects constantly and closely. If their use is found to aug- 
ment the heat of the skin, or to increase the frequency of the 
pulse, or to aggravate the delirium or stupor, it is then nec- 
essary to suspend their use. They are known to be doing 
good service, however, if they lessen the frequency of the 
pulse, and increase its fullness and strength; if the skin be- 
comes cool and moist; if the delirium is subdued or moder- 
ated, and especially if refreshing sleep be procured. Dr. 
Wood recommends the use of wine whey, prepared by add- 
ing one quart of good sherry wine to two quarts of boiling 
milk, and straining after coagulation. Of this a table- 
spoonful or more may be given every hour or every two 
hours. If the strength is greatly reduced, it may be neces- 
sary to give pure wine or brandy; or even sulphuric or 
chloric ether in cases of great prostration. Opium is also a 
useful stimulant. It may be given when the pulse is not full 
nor strong, and when cerebral symptoms do not exist. In 
the later stages it may be given in doses of half a grain, or a 
grain, every four, six, or eight hours. It is known to be act- 
ing beneficially when it promotes sleep, subdues nervous ex- 
citement, and induces gentle perspiration. Carbonate of 
ammonia is objectionable, as it may irritate the bowels and 
increase the diarrhoea. 

The diet is of the utmost importance to be attended to in 
cases of typhoid fever from the very commencement of the 
disease. It ought then to be both food and drink combined, 
in the form of a light nutritious liquid, such as meat fluid, 
soup, eggs, and milk. Barley-water, rice-water, toast and 
water, thickened more or less with solutions of tapioca, sago, 
arrow-root, the juice of sweet fruits, or the very soft pulp of 
fruits, or the pure jelly of ripe fruits; but fruit in its crude 



ENTERITIS. 141 

state is to be strictly withheld. It is necessary, as a rule, to 
give food at certain intervals and in certain quantities. A 
wine-glassful should be given at least every two or three 
hours, according to the state of digestion and the demands 
upon the strength of the patient. It may be that the patient 
is unable to swallow, from the dry and shrivelled state of his 
tongue. Before offering him food or drink, therefore, the 
nurse should put a teaspoonful of lemon juice and water into 
his mouth. She must then wait a minute or so, until the fur 
upon the tongue and mouth is softened and moist, after 
which the patient will often drink or take his food with ease. 
The patient ought to have his mouth regularly washed out 
with a linen rag, saturated with water, in which a little soda 
has been dissolved. Milk in small quantities frequently re- 
peated will be found an excellent diet; and animal broths 
and jellies may ultimately be given. The extractum carnis, 
as prepared by Liebig or Valentine, is a most valuable nutri- 
ment for typhoid fever patients. The best drink is pure 
spring water, or soda-water, or barley-water, or water that 
has been mixed with oatmeal, but is free from any particles 
of oats. The patient generally desires and requires to drink 
freely, in order to replace the loss of fluid by perspiration 
and diarrhoea; and, in the advanced stages of the fever, plen- 
ty of drink should be given by the nurse. 

The utmost caution is necessary as to diet and aperients 
during convalescence; first, as to opening the bowels, castor- 
oil or simple enemata are the only means which should be 
resorted to; secondly, as to diet, no flesh meat should be al- 
lowed till at least seven days after all the febrile phenomena 
have passed away, and the food should be as free as possible 
of excrementitious matter. Malt liquors should not be taken 
before food. 

Enteritis. — Definition. — Inflammation of the small in- 
testines generally, or limited locally. 

Treatment. — The treatment of enteritis and intestinal ca- 
tarrh, when not arising from a morbid poison, is by leeches 
to the abdomen, gentle purgative medicines, combined with 
an opiate, fomentations, and purgative or opiated enemata. 
After the inflammation has subsided, mild tonics, as the 
compound tincture of gentian, with nitro-muriatic acid, may 
be substituted, with the prospect of recovering the lost tone 
of the parts. When catarrhal diarrhoea exists, if congestion 
prevails, connected with the hepatic region, a cathartic dose 



T42 ENTERITIS. 

of calomel, followed by castor-oil. may be necessary. If the 
stools indicate an acid reaction, magnesia may be given with 
advantage. When membranous films or shreds of coagul- 
able lymph are passed, electro-galvanic applications over the 
abdomen and dorsal spinal region, combined with creasote 
or tar, in the form of a pill, is worthy of a trial (Simpson. 
Gumming, Wood). Next to those remedies are such as de- 
termine towards the skin. For this purpose combinations o f 
Dover's with James' Powder, or a solution of tartar emetic 
with laudanum, are the most useful medicines, and their 
beneficial action may be aided by the use of the warm bath, 
and a flannel roller applied with firmness round the abdo- 
men (Craigie). Where hyperoemia is excessive, accompanied 
by moderate transudation from the intestine, as after exten- 
sive burns, accompanied by great pain, cold external appli- 
cations are suitable, as well as in the severer forms of ca- 
tarrhal enteritis (Niemeyer). The best mode of applying 
them is by cloths wrung out of cold water and laid over the 
abdomen. In the chronic form, combined with obstruction, 
irritating and warm compresses are most suitable Preiss- 
nitz's compress is extensively used Tor this purpose. A wet 
towel in folds, covered with a dry one, is laid over the abdo- 
men all night, to be renewed several times daily. The great- 
est care ought to be given to the management of the diet. 
It ought to be strictly antiphlogistic, consisting of slops and 
light puddings. Animal food must be withheld, and only 
permitted in the form of soup. The safest diets are those 
of arrow-root, sago, tapioca, barley-meal, gruel of oatmeal, 
sowens, [' k The husk and some adhering starch separated 
from oats in the manufacture of oatmeal are sold in Scot- 
land, under the inconsistent name of 'seeds. These, if in- 
fused in hot water, and allowed to become sourish in this 
state, yield on expression a mucilaginous liquid, which, on 
being sufficiently concentrated, forms a firm jelly known by 
the name of ' sowens.' Not less than a quart of the seeds 
are to be rubbed for a considerable time with two quarts of 
hot water, after which the mixture is to be allowed to rest 
for several days until it becomes sour. It is then strained 
through a hair sieve, and the strained fluid left to rest till a 
white sediment subsides. The supernatant fluid is to be 
poured off, and the sediment washed with cold water; after 
which it may be either boiled with fresh water, stirring the 
whole time it is boiling, or it may be dried and prepared 
when convenient in the same manner as arrow-root. It may 



EPILEPSY AND HYSTERO-EPILEPSY. 143 

be eaten with wine, milk, or lemon-juice and sugar." — Pe- 
reira, "On Food," p. 326.] barley water, toast water, burnt 
oatcake water. This last-named substance, used as a drink, 
is said to allay irritation and morbid sensibility of the bowels 
(Craigie). When the abdominal pains subside, and stools 
become less frequent and the appetite increases, the diet 
must be still more scrupulously attended to. Oatmeal por- 
ridge boiled to the utmost degree of pulpiness, and not too 
consistent, is one of the best of diets, which may be alter- 
nated with ground rice alone, or combined with barley flour, 
all of which may be eaten with diluted milk from the cow or 
with milk undiluted of town-fed cows. 

Epilepsy and Hystero-Epilepsy. — Definition, — A com- 
plex nervous state, characterized by chronic convulsive at- 
tacks not due to organic brain disease, tonic at first, but 
which subsequently become clonic, and ultimately impede 
the respiratory process. The attack, lasting from an impc - 
ceptible period to two, twenty, or more minutes, is followed 
by some exhaustion and sleep. The expression of the epi- 
leptic state varies from simple vertigo to the most severe 
paroxysm, a momentary suspension of consciousness, a fix- 
ity of gaze, a totter of step, and a confusion which appears 
and disappears almost instantaneously, which the patient 
only can recognize. The cases comprehend — (1.) Simple 
epilepsy, or epilepsy proper, in which there is a paroxysmal 
loss of consciousness as the first, or nearly the first phenom- 
enon in the paroxysm, and with this loss of consciousness 
there is more or less spasm of muscles (including those of 
the muscular coats of the arteries). (2.)' Epileptiform seiz- 
ures, in which there is no evidence of organic brain disease, 
but developments of the movements normally represented in 
some particular parts of the cerebral cortex. (3.) Hystero- 
epilepsy (Hysteria major of Charcot, the Hysteroid of Dr. 
\V. Roberts, or the Co-ordinated Convulsions of Gowers) 
which presents, with loss of consciousness, varied convulsive 
momements of more or less co-ordinated spasm, spasmodic 
movements of a quasi-purposive character, opisthotonos, em- 
prosthotonos, and the like, forming a series from simple hys- 
teria to true epilepsy. The co-ordinated spasm may exist 
alone, or may be combined with epileptoid phenomena, or 
with true epileptic symptoms. 

Trcatme?it. — The treatment divides itself into what is to 
be done during the paroxysm, and subsequently during the 
intervals. 



144 EPILEPSY AND HYSTERO-EPILEPSY 

When adults are laboring under the paroxysm, little, in 
general, can or ought to be done except bringing the patient 
into the fresh air, taking off what may be around the neck, 
and baring the chest, together with the more imperative duty 
of preventing the patient doing himself any injury. Bleed- 
ing, so often had recourse to, is rarely found beneficial; ex- 
cept, however, as regards females, in cases of suppressed 
menstruation. If, however, the paroxysm be greatly pro- 
longed, the application of cold to the head, and opening the 
temporal artery, where symptoms of excessive cerebral con- 
gestion are obvious, may be of some service, as in cases rec- 
ognized as plethoric. It is of great importance to shorten 
the paroxysm as much as possible. Dr. Sieveking recom- 
mends that a trial be made of the galvanic current during 
the fit. The conductors should be moistened sponges, so as 
to insure the passage of the current to the deeper-seated tis- 
sues. The inhalation of ammonia or chloroform, or nitrite 
of amyl; or a dose of sal- volatile, or of ether, has been found 
useful. The nitrite of amyl not only postpones, but alto- 
gether prevents epileptic seizures. "A vinaigrette , or small 
stoppered bottle, containing a sponge soaked in nitrite of 
amyl, and carried in the pocket, so as to be at hand, will be 
found a safeguard to many sufferers from epilepsy. Where- 
ever there is time after the initiation of the coma, and before 
the development of the proper phenomena of the fit, to 
breathe the nitrite of amyl freely, the fit, with its terrible ac- 
companiments and disastrous sequelae, may in many instances 
be not merely postponed, but abolished,'' (Dr. Crichton 
Browne, "West Riding Asylum Reports," Vol. III., p. 154). 

The paroxysm over, the probable exciting cause of the 
paroxysm should be investigated, and, if possible, removed; 
the state of the bowels should be particularly inquired into 
and regulated, and leeches should be applied to the temples 
if the headache be severe. In women, also, the catamenia, 
if defective or excessive, should be remedied. These few 
simple rules are of the first importance, not only as removing 
the immediate inconveniences incident to the attack, but also 
as a means of prolonging the interval, and perhaps prevent- 
ing its future occurrence. We must take into account, and 
search out for all causes which may have contributed to the 
malady. In assuming the charge of an epileptic, it is neces- 
sary to commence first by regulating the external relations 
of the patient, his habits, and his bodily health, so that every 
suspicious condition of his life to which the origin of the dis- 



EPILEPSY AND HYSTERO-EPILEPSY. 145 

ease can in any way be ascribed may be corrected (Nie- 
meyer). In a few instances the patient, by the adoption of 
certain rules, is cured, and the prevailing principles of treat- 
ment in epilepsy mainly consist in local derivation, or coun- 
ter-irritation directed to subdue cerebral congestion, and in 
the use of such tonic remedies as may be indicated by a 
careful inquiry into the condition of the individual organs, 
and how their several functions are performed. The intens- 
ity of the headache suggests more or less active counter-irri- 
tation by blisters, dry or wet cupping, ointment of tartrate of 
antimony, setons, or even the actual cautery applied under 
chloroform to the nape of the neck. 

The medicinal remedies that have been employed are va- 
lerian, iron, zinc, quinine, musk, opium, asafoetida, the iodide 
and bromide of potassium, camphor, and the preparations of 
turpentine. The nitrate of silver, once esteemed a specific 
in this complaint, has not only failed, but, by occasionally 
staining the rete mucosum of a dingy hue, has often perma- 
nently disfigured the patient. Of the long catalogue of rem- 
edies which has been mentioned, each medicine is perhaps 
useful for a few weeks ; but after that period its good«effects 
are, for the most part, lost, so that it would appear to act 
rather mentally than physically in removing the cause and al- 
tering the morbid tendency. 

" Whatever remedies or course of treatment you pursue, 
do not appear to despond, or use any other language to the 
patient than that of hope. Avoid extravagant promises, as 
inconsistent with that love of truth which ought to character- 
ize every professional man; but unless you have the strongest 
evidence against it, do. not yourself, nor allow your patient, to 
abandon hope" (Dr. Todd, " Clinical Lectures," Medical 
Tii?ies, August 12, 1855. 

The employment of purgatives is indicated for the re- 
moval of waste matter, to act as a derivative from the head, 
to expel foreign matters or worms from the intestines, and 
generally to regulate the bowels; and the laxatives most 
suited to epileptics are rhubarb, compound colocynth pill, 
aloes, castor-oil, taraxicum, sulphur in combination with 
magnesia or rhubarb; and the Pullna, Hunyadi Janos, Fried- 
nschall, or Carlsbad bitter waters. Half a tumblerful or 
less, taken in the morning, generally produces a full pulta- 
ceous evacuation in two or three hours. The judicious use 
of an anthelmintic sometimes frees the patient from the dis- 
ease as well as from a tapeworm or other parasite, which not 
10 



I46 EPILEPSY ANJL> HYSTEROEPILEPSY. 

unfrequently may be the eccentric source of the fits. Inde- 
pendently of its anthelmintic properties, however, both Drs. 
Watson and Sieveking strongly recommend the use of tur- 
pentine. It may be given in half-drachm doses every six hours. 

If a scar, foreign body, tumor, or neuroma, be found press- 
ing on a peripheral nerve, its removal by operation may cure 
the epilepsy. Dr. Echeverria has recently given a table of 
145 epileptics who were trephined, with the results, which 
furnishes irrefragable proofs of the utility of trephining in 
epilepsy produced by injury to the cranium {London Med. 
Record, May 15, 1879, p. 169). 

The preparations of iron and zinc are the most useful ton- 
ics; and for the general principles on which iron may be ad- 
ministered, the reader is referred to the pages on Anaemia. 

Dr. Trousseau believed that belladonna is the least ineffi- 
cacious of all the remedies for epilepsy, and from its use he 
not only obtained alleviation and improvement in many 
cases, but was able to count upon a certain number of cures 
(Clinique Medicale, t. ii., p. 95). His formula is: 

Atropiae Sulphatis, gr. j.; Sp. Vini Gallici, mc. M. One 
drop of this solution is to be given every day in the morning, 
if the attacks happen in the daytime; or in the evening, if 
during the night; the dose to be increased by one drop for 
each succeeding month, and to be always taken at the same 
period of the day. It should not be pushed beyond the first 
toxical indications. If the dose is not well borne, it should 
be increased only every second or third or fourth month. 
When improvement is apparent, the quantity given in the 
last dose should be continued for some time, and then grad- 
ually lessened, and finally stopped, to be, after an interval, 
resumed. 

A year is scarcely sufficient to test the influence of bella- 
donna, and if in the succeeding year some improvement fol- 
lows, the treatment is to be maintained for two, three, and 
four years (I.e., p. 95). Dr. Trousseau, however, in prac- 
tice seems to have adopted a mixed treatment, giving bella- 
donna in the morning, with the nitrate of silver, the sulphate 
of copper, or the lactate of zinc, in the evening, alternating 
these last every ten days. The following are his modes of ad- 
ministration: 

I£. Argenti Nitratis, gr. ij.; Pulv. Acaciae, Aquae distil., 
aa q. s. Div. in pil. x. One every night. Or, 

%. Cupri Sulphatis, gr. xx.; Pulv. Sacchari, 3 j. Div. in 
pil. xx. Two every night. Or, 



EP1PLEPSY AND HYSTERO-EPILEPSY. 147 

5. Zinci Lactatis, 3j.; Pulv. Sacchari, 3 ij. Div. in 
pil. xx. One every night. Or, the zinc may be made into 
pills with the conserve of roses. 

Within the past ten years the bromide of potassium has 
been largely used in epilepsy, and the testimony to its utility 
in the disorder is uniform and strong. Dr. C. B. Radcliffe 
writes: — " In the summer of 1858 I began to give this medi- 
cine almost promiscuously in cases of epilepsy and epilepti- 
form disorder, and from that time to this (1864) I have been 
continually finding fresh reasons for persevering in the prac- 
tice. . . . The conclusion at which I have arrived is, 
that bromide of potassium is the only remedy in epilepsy up- 
on which most dependence can be placed." The late Dr. 
Bazire, in a note to his translation of Trousseau's Clinical 
Lectures, speaks thus of the experience of the physicians of 
the Hospital for the Epileptic and Paralyzed in London, 
and of his own, with this remedy: — " The results obtained 
are such as to warrant the conclusion that it is infinitely 
superior to all other remedies that have been recommended 
against epilepsy. It is certainly far superior to belladonna 
in its power of diminishing the frequency and severity of 
epileptic attacks and epileptiform seizures in general; nay 
more, of warding off the attacks, lengthening the intervals 
between them, and, in some cases, of bringing on a cure " 
The most recent, and a very high authority, Dr. J. Rus- 
sell Reynolds, in his excellent article on Epilepsy (System 
of Medicine, Vol. II., 1868), says: — "Bromide of potas- 
sium is the one medicine which has, so far as I know, 
proved of real service in the treatment of epilepsy. In large 
doses it has scarcely ever failed to give much relief. Given 
in doses ranging from ten to thirty grains, three times daily, 
it has had these effects: — In some cases it has completely 
cured the patient, and the cure has been permanent for 
years, and is so now. In others it has arrested the attacks, 
so that none have occurred for periods varying from a few 
months to two or three years; but on the omission of the 
medicine the seizures have returned. In such cases the at- 
tacks have again ceased on the readministration of the medi- 
cine. In a third series of cases it has diminished the fre- 
quency and severity of the seizures, but has not removed 
them altogether; the patients, while taking the bromide, 
have had one-half or one-third the number of fits to which 
they were habituated. Such patients have gone back to the 
old frequency of recurrence when the drug has been omitted, 



148 EPILEPSY AND HYSTEROEPILEPSY. 

and have again improved when it has been readministered. 
In a fourth, but very much smaller number, it has been good 
for a time, and then has appeared to cease; and in a fifth, 
and yet smaller proportion, it has been apparently with- 
out any appreciable effect. . . . It is to be demon- 
strated that there is yet something ' specific ' in the 
action of bromide of potassium." Dr. Voisin, of the 
Salpetriere Hospital says, that it does not cure absolutely, 
but diminishes the disorder in a marked degree, lessening 
and even suppressing the nervous erethism (Bui. de 
Therapeutique, 1867). Dr. Edward Fox reports fifty-two 
cases in which bromide of potassium, in not less than twenty- 
grain doses, was found " satisfactory," and ten cases in 
which it wholly failed, in one of which belladonna was more 
successful (St. George's Hospital Reports, Vol. II., 1867). 
Dr. Brown Sequard, than whom few have had as large ex- 
perience in this disease, began to use the bromide of potas- 
sium in large doses towards the end of i860. He writes: — 
" I was soon led to associate the iodide of potassium with 
the bromide: and it became almost at once evident that, in 
most cases of epilepsy (whether idiopathic, symptomatic, or 
sympathetic, but especially in that form, which is much more 
common than it is admitted to be, in which that convulsive 
affection is allied with or due to, a congestion of the base of 
the brain or its meninges), these two remedies did more good 
than either of them alone. By the end of 1861, after I had 
ascertained that the bromide of ammonium has a special 
therapeutic influence in cases of congestion of the medulla 
oblongata, and of the upper parts of the spinal cord, I began 
to associate that salt with the bromide and iodide of potas- 
sium in the treatment of epilepsy. . . . That mode of 
treatment has been submitted to an extensive trial, which 
leaves no doubt as regards its superiority. Although cer- 
tainly it does not often cure permanently, it usually di- 
minishes considerably, the violence and the frequency of the 
attacks, and is much more successful than the various modes 
of treatment by the best remedies against epilepsy, such as 
atropine or belladonna, the sulphate of copper, the nitrate of 
silver, strychnine, valerian, zinc, digitalis, or the means of 
counter-irritation by applications of ice, moxas, croton oil, 
&c, on the spine or head " (Lectures on the Diagnosis and 
Treatment of Functional Nervous Diseases, 1868, pp. 81, 
82). His usual prescription is: — 

IjL Potassii Iodidi, 3j-; Potassii Bromidi, 3J.; Am- 



EPILEPSY AND HYSTERO-EPILEPSY. 149 

monii Bromidi, 3 ijss. ; Potassaa Bicarbonatis, 2)ii.; Infus, 
Calumbae, f 3 vj. M. 

A teaspoonful before each of the three meals, and three 
teaspoonfuls at bedtime, in a little water. 

Dr. Ayer and others have preferred the sodium salt in- 
stead of the potassium salt, as it does not seem to have the 
same depressing effect on the cardiac muscle in large doses 
as the iodide of potassium has. It may be given in from 10 
to 30 grains three times a day. Dr. James Ayer's mode of 
prescription is as follows: — 

5,. Sodii Bromidi, Iodidi Bromidi, Ammonii Bromidi, 
aa 3 hi.; Potassii iodidi, Ammonii iodidi, aa 3" : ss., Am- 
monia sesqui-carbonatis, 3 i; Tincture Calumbae, f 3 iss; 
Aquse distillata, ad. |viii.; misce. 

The full dose of this compound is a drachm and a half be- 
fore each meal, and three drachms at bed-time. At the out- 
set the patients are informed that regular treatment must go 
on for two years, after which the dose must be left to the 
patient's discretion, when, except for averting threatened 
attacks, full doses are no longer advisable. As a tonic, 
drachm doses of the following mixture may at the same time 
be taken after each meal: — 

1^,. Strychnise sulphatis, gr. i.; Acidi sulphurici diluti m 
x. ; Aq. distillates, r§ iv.; misce. 

The strychnia may be given in smaller doses to begin with. 
In all cases the diet must be carefully regulated {Lond. Med. 
Record, March 15, 1878, p. 128). 

In syphilitic epilepsy, the iodide of potassium is increased 
to five or six drachms. Where the attacks begin with violent 
laryngismus, the bromide of ammonium is raised to three or 
four drachms, and the bromide of potassium diminished 
by two drachms. The following rules have been laid down as 
to the use of these remedies : — The quantities of these 
medicines to be taken daily should be large enough to pro- 
duce an evident, though not complete, anaesthesia of the 
fauces and upper parts of the pharynx and larynx, this quan- 
tity varying, with the patient's idiosyncrasy, from forty-five to 
eighty grains of the bromide of potassium, and twenty-eight 
to forty-five grains of the bromide of ammonium, when only 
one of these salts is given, and a lesser quantity of each, 
but especially of the ammonium, when given together 
(Clymer). 

These remedies very rarely produce a good effect in epi- 
lepsy without causing an acne-like eruption in the face, arms. 



150 . EPILEPSY AND HYSTEROEPILEPSY. 

neck and shoulders ; and there seems to be a positive rela- 
tion between the intensity of the eruption and their efficacy. 
It is important, therefore, when there is no eruption, and also 
when it begins to disappear, to increase the dose, unless the 
dose given in the twenty-four hours is already so large that any 
increase brings on great sleepiness in the daytime, a decided 
lack of will and of mental activity,dulness of the senses, droop- 
ing of the head, considerable weakness of the body, and a 
somewhat tottering gait. It is never safe for a patient tak- 
ing these drugs to be even one day without them, so long as 
he has not been quite free from the attacks for at least fifteen 
months. 

Iron and quinine should be given in epilepsy, unless the 
ailment is complicated with anaemia or malarial poisoning, 
except, perhaps, in the form of the double salt of the citrate 
of iron and strychnine. 

A gentle purge every five or six weeks maintains the power 
of the bromides (Brown-Sequard, 1. c, pp. 84-86). 

In night-seizures the bromide of potassium would seem to 
have less influence than in day-fits (Duckworth, Williams). 

The debilitating effect of the bromides ought to be lessen- 
ed by the use of strychnine, arsenic, the oxide of silver, 
ammonia, cod liver oil, cold douches or shower-baths, and a 
nourishing diet. There is an antagonism'between strychnine 
and the bromides, and when prescribed together, the dose of 
the bromides must be^ increased. 

Dr. E. C. Seguin'has also called attention, in the New 
York Medical Association, to the evil effects which may fol- 
low the abuse or over-use of the various bromides. The 
most important of these results are — conditions of impaired 
nutrition, and of nervous atony, which continued for 
months or even years ; general debility, with the weak slow 
pulse and coldness of the extremities; tendency to stupor, 
slight difficulty in speaking, the bromic breath, and acne. 
Regarding the method of using the bromide salts in the 
treatment of epilepsy and other neuroses, he lays down the 
following rules : — (1.) The prolonged use of bromides is 
contraindicated by congenital feebleness, but they are all 
borne by persons of fairly full habit, and good nervous pow- 
er. (2.) The bromides are indicated in cases of abnormally 
great irritability of the nervous system in its motor (muscu- 
lar and vaso-motor) and ideational tracts ; (3.) These con- 
traindications are to be less regarded in the management of 
that formidable neurosis, epilepsy. (4.) Epilepsy is to be 






EPILEPSY AND HYSTEROEPILEPSY. 151 

regarded as the only disease which justifies the deliberate- 
production of a degree of bromism for its cure. 

Dr. Seguin's method of prescribing the bromides in the 
treatment of a case of " idiopathic " epilepsy is the follow- 
ing. Two solutions are employed. 

r>. Potasii bromidi, § i.; Ammonii bromidi, 3 ss. Aquas 
fontanse, 3 vij.; misce : to be given by the teaspoonful ; and, 
I£. Sodii bromidi, | i. ; Ammonii bromidi, § ss. ; Aquae font., 
3 vij.; misce : to be given by the teaspoonful. 

The quantity administered is to be so divided as to give by 
far the largest dose in the evening. The bromide is to be cau- 
tiously increased, still keeping the nocturnal dose the largest, 
until slight bromism is produced; which is usually necessary to 
be maintained for months, but just as little is to be given as may 
prevent the attack. The precise quantity required must be 
studied in each case. Children tolerate the bromides, as well 
as the iodides, in relatively large doses. It is of importance to 
thoroughly dilute the bromides in order to facilitate their ab- 
sorption — the dose to be taken in a wineglassful or half a 
tumblerful of water. Under no circumstances should the 
bromides be discontinued; they may be diminished, but not 
stopped entirely ; they should be continued at least three 
years after the last attack. The adjunct treatment consists 
in the use of measures to prevent the acne to a certain ex- 
tent, such as the occasional use of arsenic, sulphur-ointment, 
mercurial plaster, alkaline lotions ; to correct the general de- 
bility of slight paresis, by the use of strychnia, mix vomica, 
oxide of zinc, and quinia: to relieve the dizziness by the in- 
halation of nitrite of amyl, by stimulants, and quinia; reg- 
ulating the patient's diet and hygiene, and the use of cream, 
cod-liver oil, iron, quinine, phosphorus, strychnia, with nitro- 
muriatic acid. In certain cases such medicines as acted more 
directly upon the morbid state of the nervous centres were 
associated with the bromides, and favorite among these was 
belladonna {London Medical Record, June 15, 1877, p. 221). 

Picrotoxine has been found to possess anti-convulsive prop- 
erties. It was originally recommended by Dr. Crichton 
Browne in the treatment of epilepsy, and his experiments 
have been recently confirmed by Planat. 

Clinical familiarity with epilepsy, and a history of its the- 
rapeutics go to show that there are no grounds for belief in 
any specific against this affection, and the physician who 
promises a cure, or even relief, by means of any one remedy in 
this disorder, runs the risk of damaging not only himself, but 



152 EPILEPSY AND HYSTEROEPILEPSY. 

his art. It cannot, however, be doubted, that, in a certain 
number of cases of epilepsy not apparently caused by any 
coarse cerebral lesion, the severity and frequency of the 
seizures may be greatly abridged, so that the sufferers may 
be brought to enjoy often a great degree of immunity and 
comfort. The proportion of such cases to the whole num- 
ber afflicted is, perhaps, few, but it is still sufficiently numer- 
ous to give hope and encouragement to further trial. Such 
results, however, can only be surely gained by means which 
will increase and develop the vital power generally. It should 
be borne in mind that tonic treatment does not alone consist 
in the administration of a tonic drug. Whilst many cases of 
epilepsy demand the use of tonic medicines to fulfil certain 
present indications, they should in no sense be looked on as 
a curative, or even remedial, but only as adjuvants, and when 
they have done their work should be laid aside. Of this 
class of remedies none, perhaps, is more valuable than arse- 
nic, given in minute doses. Where there is anaemia, iron or 
manganese is required. But a general restorative system 
must be adopted and persevered in. 

The diet of the epileptic should not consist of much meat 
(nor much nitrogenized food), nor much of anything. It 
ought to be spare diet — simple and unstimulative, and to 
the absolute exclusion of alcohol. After a prolonged inves- 
tigation on the influence of diet in epilepsy, carried on at 
the West Riding Asylum, by Dr. John Merson, he came to 
the conclusion that a farinaceous diet is likely to be more 
useful in the treatment of epilepsy than a nitrogenous one 
{West Riding Lzmatic Asylum Repo?'ts, Vol. V., p 1). The 
food should contain, as soon as the state of the digestive 
organs will permit, a certain portion of fatty and oily con- 
stituents, and in most cases cod-liver oil may be given with 
advantage. The hypophosphites, as a vehicle for the intro- 
duction of phosphorus into the system, would seem to be 
of service in improving the general nutrition. 

The maintenance of the activity of the cutaneous function 
is of the first importance. In the beginning an occasional 
vapor or hot-air bath may be taken ; afterwards tepid salt or 
fresh-water baths, followed by a general grooming of the 
skin. Exercise in the open air, gymnastics, both measured 
by the strength of the patient, are to be insisted upon, as 
well as such means as will promote the expansion of the 
lung tissue. With physical training, mental and moral train- 
ing should be combined. 



EQUINIA ERYSIPELAS. 153 

Such are the general principles of the rational or restora- 
tive treatment of epilepsy, which, it is believed, will give a 
larger measure of success than a reliance upon any one of 
the innumerable specifics that have had questionable and 
temporary repute. If a successful issue is to be had, per- 
severance and confidence, both on the part of the physician 
and the patient, are chief conditions of success, and this 
should be fairly stated at the outset to the sufferer and his 
friends. 

Ice applied to the cervical spine has caused the severe 
paroxysms of hystero-epilepsy to cease (Gowers). 

Eqilillia — See Glanders. 

Eqilillia Mitis. — Definition. — A pustular eruption, pro- 
duced by the contagion of matter from a horse affected with 
the grease. 

Treatment. — The greatest relief to the constitutional dis- 
turbance is obtained by frequent purgation with aloes com- 
bined with ammonia, and such moist local applications as 
may relieve pain. 

Ergotism. — Definition. — A train of morbid phenomena 
produced by the slow and cumulative action of a specific 
poison in a fungus peculiar to wheat and rye, and which 
gives rise to convulsions, gangrene of the extremities, and 
death, or to symptoms of ill-health. 

Treatme?it. — Considerable differences of opinion prevail 
regarding the treatment of this dietetic disease. The cause, 
in the first instance, must be ascertained and removed ; and 
to obviate the effects it has already produced, the constitu- 
tional treatment must be directed to improve the state of the 
blood. Tonics and stimulants are to be administered, after 
a free employment of evacuant remedies, to clear out the 
alimentary canal completely. The chlorates of potash and 
of soda, with antispasmodics, tonics, and narcotics, are 
especially indicated. Camphor, musk, ammonia, capsicum, 
may be particularly mentioned ; and the strength of the 
patient is to be supported by light, nourishing and whole- 
some food. 

Erysipelas. — Definition. — An acute febrile disease, char- 
acterized by a peculiar inflammation of the integument, tend- 
ing to spread indefinitely, and even to involve the areolar 
tissue beneath the skin. It is accompanied by severe gen- 
eral symptoms. 

Treatment. — " Experience has proved that general bleed- 
ing has no other effect than to blanch the eruption, without 



154 ERYSIPELAS. 

notably abridging its duration ; " and from the nature of the 
disease blood-letting in any form is not to be thought of. 
Rest, saline laxatives, cooling drinks and low diet are the 
elements of treatment in mild and simple cases. An emetic 
is useful at the commencement; and I have seen, in the 
practice of an eminent surgeon (Mr. Syme) that frequent 
resolution of an erysipelatous attack has followed an antacid 
laxative, such as forty grains of rhubarb to sixty of bicarb- 
onate of soda, divided into twelve powders, one to be taken 
every six hours, together with the counter-irritation of a 
mustard poultice over the stomach. Laxative and cathartic 
remedies are to be selected and apportioned according to the 
violence of the attack and its nature, as tending to the un- 
favorable results of the specific inflammation already noticed. 
Calomel is a most valuable purgative, as a sedative in febrile 
disturbance, especially when followed by castor-oil, or the 
common black draught. The indications to the use of cer- 
tain remedies, as given in the treatment of scarlet fever, are 
equally applicable here. If the febrile state is not subdued, 
antimonials are of great service ; and so far as they are diapho- 
retic in their action they tend to subdue the vascular ex- 
citement. If symptoms of nervous depression ensue, opium, 
or opium and ipecacuanha are indicated, also wine and quin- 
ine, ammonia and camphor, in asthenic cases with a tendency 
to a typhoid state. The tincture of the perchloride of iron, 
in doses of ten to thirty minims, three, four, or five times a 
day, in water, infusion of quassia, or calumba, is now also a 
remedy much in use, and it may be alternated with the syrup 
of the phosphate of iron, in doses of a teaspoonful three or 
four times a day. In cases where the system is obviously 
gouty or rheumatic, and where the joints are affected, col- 
chicum with saline diaphoretics are the most efficient reme- 
dial agents. Local applications are potent for good or evil, 
and must therefore be used with great caution. The effects 
seen on the skin do not constitute the whole disease ; and if 
the development of these processes on the cutaneous tissue 
is imprudently interfered with, there is imminent danger to 
internal organs. To check the advance and prevent the en- 
croachment upon new territory, rather than to subdue it, if 
already in possession, ought to be the sole aim of local treat- 
ment, and to mitigate the local pain and uneasiness. Bland 
mucilage, such as that of viscid linseed tea, from which light 
muslin cloths have been steeped and spread over the inflamed 
surface, sometimes affords relief. Dry flour, or rye-meal, 



ERYSIPELAS. 155 

frequently dusted from a dredge-box over the erysipelatous 
patches, are soothing applications. A thick layer of cotton- 
wool dusted with tutty powder is also a soothing application 
to the part. A lotion of nitrate of silver painted daily over 
the affected parts sometimes gives great relief (one scruple 
of the nitrate to an ounce of water, to which ten drops of 
dilute nitric acid are added). Dilute nitric acid should, at 
the same time, be given internally, if typhoid symptoms pre- 
dominate, as in the following formula : 

IjL Acid. Nitrici dil., 3i-| Syrup. Zingib., 3 ss. ; Aquas, 
3 vss. ; misce. A tablespoonful every four hours. 

To arrest the spread of the process over sound skin, ni- 
trate of silver in very strong solution, or tincture of iodine 
have been considered efficient agents. A line of circumval- 
lation is to be painted round the erysipelatous part, so as 
completely to enclose it. The nitrate of silver should either 
be employed in the solid stick; or as proposed by Higgin- 
botham, in solution of eight scruples of the nitrate with 
twelve drops of nitric acid in a fluid ounce of water. Dr. 
Wood has practised with success and recommends the use of 
tincture of iodine. But in this country the boundary line 
of nitrate of silver has not been attended with success ; and 
our best surgeons are now discontinuing the practice as a 
useless source of irritation (Erichsen, Campbell De Morgan). 
Sulphite of soda, in solution of ten grains to one ounce of 
water, is recommended by Dr. Addinell Hewson, of Phila- 
delphia. He has never seen it fail to arrest the progress of 
the disease, if it has not advanced to the deeper parts below 
the skin. Lint soaked in the solution is to be applied to the 
affected part, and over a considerable distance beyond any 
visible appearance of redness. The lint is to be covered 
with oil-silk, to prevent evaporation. The application of 
sulphate of iron as a lotion or ointment tends to shorten the 
disease. In lotion, one drachm of the salt to a pint of 
water ; in ointment, a scruple to an ounce of lard (Velpeau, 
Luke, De Morgan). It has the inconvenience, however, of 
soiling linen with which it comes in contact. None of these 
lotions should be applied cold, but tepid or warm. Collodion 
and iodized collodion are also worthy of commendation. 
Long and deep incisions into the inflamed textures are some- 
times demanded. This is more especially the case if there 
be tension of fibrous tissue, such as the subcutaneous 
fasciae ; and erysipelas of the head is frequently greatly 
alleviated by repeated innumerable minute punctures, made 



I56 ERYTHEMA FEVER, REMITTENT. 

by the point of a lancet all over the parts of the face and 
scalp which are affected. 

Erythema. — Definition. — Uniform redness simply, with 
puffiness of the skin, distributed in distinct patches of some 
size. 

Treat?7ient. — Rest, quinine, and iron, after aperients ; car- 
bonate of ammonia, after gentle purgation, in doses of 5 to 
10 grains three times a day, are the most useful remedies. 
Oxide of zinc, in fine powder, dusted over the surface, will 
sometimes allay the local irritation. 

Favus — See Tinea Favosa. 

Febricilla. — Definition. — A simple fever in which the 
expression of the febrile phenomena is of very short dura- 
tion, lasting, as a rule, for not more than twenty-four, thirty- 
six, forty-eight, or seventy-two hours, attended with a fre- 
quent, full, and often firm pulse, white and coated tongue, 
pains in the loins and limbs, thirst, constipation, a scanty 
discharge of high-colored urine, hot and dry skin, sometimes 
an eruption of roseola or erythema about the loins or thighs, 
coming and disappearing with the fever (Morehead) ; severe 
headache, sometimes acute delirium, and flushed face. The 
subsidence of the fever is generally associated with copious 
perspirations, or herpetic eruptions. 

Treatment of Febricula. — Such means as emetics, purga- 
tives, tepid sponging, diaphoretics, and antiphlogistic regimen 
are to be employed. In plethoric individuals, where there is 
much headache and flushing of the face, leeches to the tem- 
ples may be expedient, but such remedies are not often 
necessary (Morehead). 

Fever and Ague. — See Ague. 

Fever, Break Bone — See Dengue. 

Fever, Cerebro-Spilial — See Cerebro - Spinal Menin- 
gitis. 

Fever, Bandy — See Dengue. 
Fever, Enteric — See Enteric Fever. 

Fever, Intermittent — See Ague. 

Fever, Malignant Purpuric — See Cerebro-Spi?ial Men- 
ingitis. 

Fever, Puerperal — See Puerperal Fever. 
Fever, Relapsing — See Relapsing Fever. 
Fever, Remittent — See Remittent Fever. 



FEVER, RHEUMATIC GASTRITIS. 157 

Fever, Rheumatic — See Rheumatism, Acute. 
Fever, Typhoid — See Enteric Fever. 
Fever, Typhus — See Typhus Fever. 
Fever, Yellow — See Yellow Fever. 

Gall-Bladder, Inflammation of. — Definition. — Inflam- 
mation, generally catarrhal, but occasionally croupous or 
diphtheritic, of the mucous membrane of the biliary pas- 
sages. 

Treatment is similar to that of catarrh of the intestines, 
and especially in the use of nitro-muriatic acid internally and 
as baths. 

Gall-Stones — See Colic, Biliary. 

Gastritis. — Definition. — Forms of inflammation tending to 
exudations and destruction of parts, or condensations of tis- 
sue, especially about the pyloric opening. 

Treatment. — Emetics may be required in cases where the 
stomach has been overloaded; and it is certain, from the 
gases and fluids causing prominence over the stomach, that 
it contains decomposing food. One scruple of ipecacuanha, 
with one grain of tartrate of antimony, is tne safest and most 
efficient emetic. When injurious matters have passed into 
the bowels, causing flatulence and colicky pains, mild laxa- 
tives may be required, such as rhubarb; or, compound infu- 
sion or mixture of senna, or fluid magnesia, in small doses, 
may be given every hour or two hours, followed by five or 
ten grain doses of bicarbonate of soda. In chronic or passive 
congestion of the stomach, and in chronic gastritis, the ad- 
vantage of nitrate of silver has been advocated by the late 
Drs. James Johnson and Symonds, and more recently by 
many other physicians. Argent. Nitrat.,gr. ^, Ex. Hyoscyam., 
gr. ii. to gr. iv., made into a pill, may be continued every 
night, the quantity of the nitrate being gradually increased 
to two or three grains daily. It may not be continued, how- 
ever, beyond six or eight weeks. Or Argent, nit. Crystal, 
gr. ss. to gr. i, Aq. distilat., f 3 ss; may be taken at bedtime — 
the stomach being empty — and repeated every night, or every 
second, third, or fourth night, according to the severity of the 
gastric symptoms. I have found Seller's mixture of Bismuth of 
great advantage ;and alkalies combined with morphia. In cases 
of acute gastritis, mercurial purgatives by calomel are of ser- 
vice. Three to five grains may be given to an adult; followed 
by a dose of castor-oil or the compound senna mixture of the 



158 GLANDERS GLOSSITIS. 

pharmacopoeia. Where it is not desirable to act so search- 
ingly on the small intestines, blue pill with compound colo- 
cynth or rhubarb pill in equal parts (a a gr. ii.), combined 
with one grain of ipecacuanha powder, is a mild and gentle 
laxative. Iced water to drink in small quantities, or small 
pieces of ice in the mouth, tends to allay thirst, and to ap- 
pease pain; and the continuous use of hot water fomenta- 
tions over the region of the stomach, as hot as the patient 
can bear them, is of great benefit (Brinton). 

Grlailders. — Definition. — A specifie catarrhal inflamma- 
tion of the nasal mucous membrane, produced by the conta- 
gion of matter from a glandered horse, and intercommuni- 
cated between men and horses. It is a febrile disease of a 
malignant type, characterized by vascular injection of the 
nasal mucous membrane, from which an aqueous, viscid, 
glutinous, or purulent discharge proceeds. Chancre-like 
sores are formed on the mucous surface of the mucous mem- 
brane extending to the frontal sinus and neighboring mucous 
surfaces. The lymphatic glands enlarge in the vicinity of 
these mucous membranes. 

Treatment. — All the remedies hitherto tried in acute glan- 
ders have failed. The advent of typhoid symptoms has led 
to the administration of quinia, valerian, serpentaria, am- 
monia, and other stimulating medicines. In the more chronic 
forms of the disease the recovery of the patient has appeared 
to be owing to the excellence of his constitution; during the 
natural elimination of the poison, to good ventilation, and to 
generous diet, rather than to any effect produced either by 
general or local treatment. 

Preventive Treatment. — The prophylactic treatment is the 
same as that of all other contagious diseases — namely, being 
careful to avoid all contact with the morbid poison, espec- 
ially when a finger or other part of the hand is abraded; and 
if by accident the veterinary surgeon' should inoculate him- 
self, he ought instantly to destroy the part withpotassa fusa. 
It has been recommended, after the disease has been set up, 
to extirpate the enlarged glands; but this practice is as un- 
warrantable as hopeless. 

German Measles — See Measles, German. 
Glossitis. — Definition — Inflammation of the tongue. 
Treatment. — Active cathartics are generally of great service, 



GOITRE. 159 

and they are to be given as enemata. Blood must be taken 
directly from the tongue in such cases. Incisions along the 
superior surface of the inflamed organ, followed by the action 
of the vapor of hot water, may reduce the swelling and re- 
lieve congestion. The relief afforded by these measures is 
frequently almost instantaneous. Two or three applications 
of six leeches at a time to the inflamed parts may produce a 
speedy decrease of the tumor (Graves). If suffocation is 
imminent tracheotomy or laryngotomy must be performed. 
Erythematous inflammation of the tongue with generally 
yield to a combination of bismuth in glycerine, such as bis- 
muthi subnitratis, gr. xx,; glycerini, fi,; aquae. § vii. Of 
these make a lotion with which to wash the mouth and 
tongue. 

Morbid sensibility of the tongue may be soothed by a weak 
solution of bromide of potassium, 3 ss. 3 i. to § vi. of water, 
used as a mouth-wash (Symonds.) 

Goitre. — Definition. — An enlargement of the thyroid 
gland, by some regarded as specific, and induced by the per- 
sistent use of water which has percolated through magnesian 
limestone rocks, or strata containing the soluble salts of 
lime in solution; or it is regarded as a circulatory disease, 
the two-fold blood and nerve supply of the thyroid gland 
being favorable to its enlargement under conditions of ex- 
cessive and constant muscular exertion. 

Treatment. — The indications are — (1.) To remove from 
the district where the disease prevails : (2.) improvement of 
the water used as drink ; (3.) elimination of the goitrous 
poison, or change of constitution. As with the poison of 
mercury and of lead, so with goitre, iodide of potassium has 
a wonderful effect in subduing the swelling, and probably, in 
eliminating the poison which produces goitre, whatever that 
may be. Iodine has thus acquired the reputation of being 
almost a specific against goitre (Coindet, Straub, Gairdner, 
Manson, Lugol). In robust subjects it has been advised 
that the administration of iodine should be preceded by 
general blood-letting, on the principle that the abstraction of 
blood favors absorption ; but this should not be done unless 
the iodine does not seem to be producing any effect ; and 
whatever may be the preparation of iodine employed, it must 
be persevered in for a length of time, and the dose gradually 
increased (Dunglison). The best form of administration is 
that in which the iodine is mixed with and dissolved by 



l6o GOITRE. 

iodide of potassium. It is then held in solution, and is 
sometimes known as Lugol's solution. It is made by dis- 
solving one part of iodine (five grains) with two parts of 
iodide of potassium (ten grains), and adding water (to the 
extent of one pint). It contains one grain of iodine in four 
ounces of the solution. The treatment ought not to com- 
mence with a larger dose than one drachm three times a day. 
Small unirritating or alterative doses are the most efficient, 
and they may be gradually increased when necessary. The 
remedy may also be employed externally, in the form of a 
liniment or ointment — the unguentum iodum compositum, of 
which a small portion may be rubbed upon the swelling night 
and morning. In some parts of India the application of an 
ointment of the biniodide of mercury has been found effica- 
cious. The ointment is prepared by adding finely- 
powdered biniodide of mercury to melted lard or mutton 
suet or vaseline (in the propo tijn of 15 grs. of biniodide 
of mercury to 1 ounce of lard. This ointment is then 
applied to the goitre about an hour after sunrise, and is 
rubbed in, by means of an ivory spatula, for about ten min- 
utes — the patient sitting with his goitre held well up to the 
rays of the sun as long as he can bear the exposure. The 
ointment may produce a blistering effect, although no vesi- 
cles appear on the skin ; and in the course of the day it 
should be gently rubbed in again, and the patient sent home, 
with orders not to touch it with his hands, but to allow the 
ointment to be gradually absorbed. A second application is 
sometimes necessary in very bad cases. In 1855 no less than 
500 or 600 persons were sometimes treated in a single day ; 
and it is estimated that altogether about 60,000 patients have 
been so treated ; so that the cases in the district are now far 
less numerous than formerly, and the disorder is thus being 
extinguished (Mouat, in Indian Annals for April, 1857). 
When medical treatment fails, surgeons have attempted to 
give relief by one of three operations ; but so long as the 
disease does not interfere with any of the important func- 
tions of the body, nor produce serious discomfort, surgical 
interference is not warrantable. These operations are, — (1.) 
The introduction of setons through the tissue of the diseased 
gland — an operation which has been successful. A thin 
double wire is to be passed through the gland, and left there 
for a week (Quadri, Tanner, James). (2.) Tying the thyroid 
arteries which supply the goitre with blood, and so starving 
the tumor, has been attended with varied success (Coates, 



GOITRE GONORRHOEAL RHEUMATISM. l6l 

Brodie, Earle, Wickhara). These means having failed (3.) 
the gland has been extirpated — an operation which few sur- 
geons would now think of undertaking. 

Regarding these surgical interferences for the radical cure 
of goitre, Sir Thomas Watson observes, that " there is not 
one of which the average results have been sufficiently pros- 
perous to warrant its repetition, except in cases where life is 
put in jeopardy, or made miserable by the swelling; and where 
other methods, and particularly the treatment by iodine, 
have been tried and have failed " (" Principles and Practice 
of Physic," Vol, L, p. 795). He makes, however, an excep- 
tion in favor of puncturing any cell or cyst containing fluid, 
which sometimes makes up a considerable portion of the 
tumor. Such cysts may be punctured without much risk, 
and with great relief to the patient. 

Goitre, Exopthalmic. — Definition. — Enlargement with 
vascular turgescence of the thyroid gland, accompanied by 
protrusion of the eye-balls, anaemia, and palpitation. 

Treatment. — The use of iron and tonics generally are in- 
dicated; and the use of digitalis may be indicated in con- 
nection with the cardiac symptoms. The indications for 
treatment are, to allay the irritability of the stomach by the 
use of ice ; to give bland, unstimulating, nutritious food in 
small quantities and at short intervals; to produce sound and 
refreshing sleep by morphia, or any such stimulating sopori- 
fic; to administer digitalis; to steady the weak heart and con- 
trol its excitement. Iron may improve the state of the 
blood; but the hygienic conditions in which the patient lives 
are mainly to be rectified (Fletcher). Dr. J. Warburton 
Begbie recommended the use of belladonna in combination 
with iron (" Dublin Quarterly Journal of Medical Science," 
Nov., 1865, by Dr. W. Moore). 

Gonorrheal Rheumatism. — Definition. — An affection 
analogous to acute rheumatism, associated with gonorrhoea. 

Treatment. — The condition of the digestive organs gener- 
ally requires attention and correction. Anodyne fomentation 
generally affords relief to the pains of the joints. Dover's 
powder is to be given in the acute stage at intervals; and 
after the more acute symptoms have been subdued, the 
greatest benefit is obtained from blisters, repeated several 
times, when effusion within the capsule of the joint is a 
prominent symptom. An electuary of guaiacum, sulphur, 



1 62 GOUT, ACUTE. 

and cream of tartar (in equal proportion) in glycerine I have 
found of use. Vapor baths and Turkish baths are both of 
great service. The gonorrhoea must be cured as soon as 
possible by the usual remedies. 

The preparations of iron, iodine, quinine, combined with 
ammonia, potass, or soda, in bitter vegetable infusions, ac- 
cording to the nature of the urinary symptoms, are the best 
tonic remedies, together with fresh air and good diet. 
Iodide of potassium ought to be used in the chronic form 
of the disease. Pressure over the joint by strips of adhesive 
plaster, aided with bandaging from the toes upwards, is often 
of great service in subduing the swelling which remains, 
after all other symptoms have subsided. Passive motion 
must afterwards be used. 

GrOUtj Acute. — Definition. — A specific febrile disorder, 
characterized by non-suppurative inflammation, with con- 
siderable redness of certain joints, — chiefly of the hands and 
feet, and (especially in the first attack) of the great toe; at- 
tended by excess of uric acid in the blood, and probably 
also of phosphoric acid. The constitutional affection tends 
to culminate, at longer or shorter intervals, in a paroxysm, 
or " fit of the gout," when various joints, textures, or parts 
of the body are apt to become affected. 

Treatment. — Seeing that the disease is clearly of constitu- 
tional origin, its treatment resolves itself into — (i.) The 
selection and administration of those remedies which shall 
tend to subdue, control, or eradicate the latent disposition, 
constitutional tendency, or gouty diathesis; (2.) The adop- 
tion of such means as may be safely used to modify the 
severity of or shorten the paroxysms. The paroxysm must 
be interfered with cautiously. It is the means which 
nature takes to rid the constitution of the materies morbi, 
and which it undoubtedly relieves for a time, if allowed to 
run its course. But the removal of the paroxysm, or its 
subsidence, does not necessarily remove the constitutional 
diathesis. That must be modified by promoting the trans- 
formation of the tissues of the body as much as possible in 
a healthy way. As to any local treatment during the fit, 
Sydenham writes, " If outward applications be required to 
ease the pain of the gout, I know of none, though I have 
tried abundance both on myself and others, and I have laid 
aside the use of topical remedies for many years." It is 
generally admitted that cold is dangerous, while warmth is 



GOUT, ACUTE 163 

productive of little relief. In some instances the urate of 
soda is deposited in such quantity that the skin ulcerates, 
and the salt is discharged in considerable abundance in a 
fluid state. It might appear the right practice to apply a 
poultice and encourage the discharge, in order that, by its 
entire removal, the joint might be saved. This, however, is 
by some considered dangerous practice, for the discharge is 
so debilitating that patients are said to have sunk under this 
mode of treatment. It is much safer to wait till the chalk- 
stone becomes concrete, and then operate, by the smallest 
possible incision, for its removal. With respect to the use 
of cold water, the practice is as old as Harvey, and subse- 
quently it has been adopted and abandoned by many prac- 
titioners. Dr. Parry had at one time two patients who at- 
tempted to cut short the fit by plunging their feet in cold 
water. The relief was instant, but in a few hours both were 
dead of apoplexy. The fatal result of this remedy in Sir 
Francis Burdett's case is another instance in point. " A gen- 
tleman," writes Dr. Wood, " contrary to the advice of his 
physician, and anxious for speedy relief, ordered a bucket 
of water to be taken into his chamber at bedtime, with the 
view of employing it in this way. In the morning he was 
found dead in bed." 

Antiphlogistics neither alleviate the pain of gouty inflam- 
mation nor shorten the attack ; while their untimely use, es- 
pecially general and local bleeding and active saline purges, 
favors the passage of acute into chronic gout. Rest is ab- 
solutely necessary. Warm anodyne lotions or fomentations 
may be used, and the part afterwards lightly covered or en- 
cased in flannel or fine wool, while the limb is at the same 
time kept elevated. The " bootikins " of Horace Walpole, 
so strongly recommended and given away by him to all his 
gouty friends, seem to have been merely a fine bandage of 
flannel, applied moist and firmly over the limb, and then a 
roller of oiled silk over it, giving moist warmth like a poul- 
tice. Writing to Horace Mann, he says, — " You must put 
them on at night, and tie them as tight as you can bear — the 
flannel next to your flesh, the oil silk over. In the morning, 
before you rise, you must dry your feet with a hot napkin, 
and put on a pair of warm stockings freshly aired. Over the 
bootikins at night draw a pair of thread stockings " (" Life 
and Letters, Vol. VII., p. 224). Dr. Wood uses a warm 
mixture of tincture of camphor with milk, applied by means 
of linen compresses, and frequently renewed. Tincture of 



164 GOUT, ACUTE. 

aconite may be similarly applied (f 3 iss. to f § iv. of milk). 
The hypodermic injection of a fourth to a third of a grain 
of muriate or bimeconate of morphia, in any convenient part 
of the body, often relieves the local pain. Blisters have been 
recommended, and are of most advantage in asthenic chronic 
cases, when the inflammation has a tendency to linger in the 
articulations, and to cause liquid effusion. In the early fits 
of sthenic gout they are unnecessary ; and are contraindi- 
cated in advanced gout, when the kidneys have become im- 
paired, and also in cases of extreme gouty deposits (Garrod). 
As a general rule, however, the less that is done to the local 
affection the better. When the pain is very intense, relief 
may be given by the application of a solution of atropine, 
made by dissolving from two to three grains of the alkaloid 
in a weak mixture of spirits and water, and applying it to the 
inflamed joint by means of compresses of lint, preventing 
evaporation by a covering of oil silk (Garrod). 

In the general treatment of gout bleeding is now generally 
restricted to two methods, namely — (1.) By leeches to the 
part where the inflammation rises so high, or is so chronic, 
as to threaten the patient with the permanent loss of the use 
of some joint ; and to cases of metastasis of the disease to 
the stomach or other internal organ, when leeches are abso- 
lutely necessary ; (2.) By general blood-letting. The fol- 
lowing rules are laid down by Dr. Garrod as to the use of 
bleeding in gouty cases : — (1.) Never bleed with the idea of 
directly subduing gouty inflammation ; (2) Never bleed in 
advanced gout, or when the constitution is much weakened; 
(3.) If bleeding be required in order to relieve general or 
local plethora, abstract only as much as will effect that ob- 
ject, remembering that further depletion tends greatly to ag- 
gravate the disease and prolong its duration. Blood-letting 
produces a decided sedative action on the heart and other 
parts of the circulating system, and it has a most powerful 
influence upon the progress of gouty inflammation — an influ- 
ence not merely limited to the removal of gout when it at- 
tacks the joints, but also of great efficacy in its marked and 
irregular forms, in the ophthalmia of gouty habits, in gouty 
bronchitis, and in headaches connected with the gouty dia- 
thesis (Sir H. Holland, Garrod). 

With regard to purgatives, Sydenham, who was as great 
an enemy to purging as he was to bleeding, says, — " I am 
abundantly convinced, from much experience, that purging, 
either with mild or strong cathartics, whether used during 






GOUT, ACUTE, 165 

the fit or in its declension, or in a perfect intermission or 
healthy state, . . . endangers the life of a patient by 
hurrying on the disease to the viscera, which were quite safe 
before." The objection taken by Sydenham to purgatives 
was quite valid against those in use in his day, which we're 
of the most drastic kind ; but it may be laid down as a rule 
that neutral salts are not only safe but efficient in relieving 
gout, though perhaps not to be depended on alone for its 
cure. The theory on which they are prescribed is, that the 
alkaline base of the neutral salt is absorbed, and combines 
with the insoluble urates deposited in the joints, forming a 
soluble sub-urate, which can readily be absorbed ; and, 
again, more alkali being sent to the kidney, that organ is en- 
abled to remove more uric acid, in a soluble state, from 
the system than under ordinary circumstances. The salts 
most in use are the sulphates of magnesia or of soda, and 
especially the former ; and half a drachm to a drachm should 
be given every eight, six, or four hours, according to the 
state of the bowels and the acuteness of the symptoms. It is 
also necessary to afford some relief to the patient from his 
excessive suffering. With that view an anodyne should be 
added, such as the tincture of hyoscyamus, syrup of poppies, 
or some preparation of opium. This method of treatment 
relieves the patient and shortens the paroxysm ; but when 
the relief is complete, it should be abandoned, for sometimes 
a paroxysm of gout will return even under its use. Colchi- 
cum, or meadow-saffron, was long ago introduced as a spe- 
cific in gout, of which the once popular " eau medecinale " 
was supposed to be a preparation. Colchium in some cases 
seems to be almost specific in its effects, and may be given 
as an extract or tincture, or as a wine, combined with some 
form or saline draught. Its mode of action is unknown. It 
very generally promotes secretion from the skin and kidneys; 
but it is useful even when it does not exercise any such 
physiological action. The quantity of uric acid and urea in 
the urine is said by some to be increased during its use 
(Chelius). Dr. Graves makes an opposite statement ; and 
Dr. Garrod proves conclusively that colchicum does not in- 
crease the amount of uric acid. Dr. Laycock suggests that 
it may have a sedative effect on the vital actions going on 
in the tissues themselves, and so may arrest the formation of 
the gout poison. The wine of the root of colchicum is gen- 
erally the form preferred, ten to fifteen or to thirty minims 
being given every four, six, or eight hours, and this remedy 



l66 GOUT, ACUTE. 

ought to be continued for some time in reduced doses, after 
all symptoms of gout have disappeared (Budd). The bowels 
ought to have been freely moved before colchicum is given ; 
and a full dose having been given at first, -much smaller 
doses may be continued, as from ten to twenty minims two 
or three times a day, in Seltzer or Vichy water, or in other 
alkaline solutions, such as bicarbonate of potash much di- 
luted, or combined with iodide of potassium, carefully 
watching its effects on the pulse, and never allowing sick- 
ness or depression to ensue. It may also be given with car- 
bonate of lithia. Scudamore's mixture of colchicum, mag- 
nesia and sulphate of magnesia, is said to be an excellent 
purgative in gout when a purgative is required. Although 
Dr. Garrod has shown that purging is not necessary to the 
action of colchicum, yet, there are many who believe that 
the action of colchicum is promoted by its combination with 
laxative remedies. Abernethy was wont to prescribe, — 

1^ Sodae phosphatis ; Sodae sulphatis — aa 3 iv. ; Aramo- 
niae sesqui Carb., 3 ss. ; Acid benzoici, gr. xx. ; Vin. sem. 
Colchici, 3 iss ; Infus. Calumbae, ad 5 viii., of which a sixth 
part is to be taken every four or six hours. 

Dr. Wood is in the habit of using it in the following for- 
mula in a draught : — 

fy Magnesise, 3 ss. ; Magnes. Sulphat., 3 ss. ; Vin. Col- 
chici. rad., m xx. ; Aquae Fluv. vel Aq. Acid Carbon., f § iss. 

Mercury in the form of " blue pill," or in the form of the 
" compound calomel pill " (Pil. Plummeri), followed by the 
draught just written, is useful where it is desired to act upon 
the intestinal secretions. But mercury in any form must not 
be given if the urine contains albumen. If mere constipa- 
tion is to be got rid of, rhubarb pill, colocynth and scam- 
mony pill, or podophyllin, may be advantageously used. 
The iodide of potassium has been much recommended by 
Mr. Spencer Wells. Alkaline remedies are of much value 
in the treatment of the paroxysms of the joint affection, and 
may be prescribed in the form of the bicarbonate, or of the 
citrate or acetate of potash. Dr. Garrod prefers the bicar- 
bonate, and Dr. Parkes has shown that it increases the elimi- 
nation of uric acid and organic solids by the urine (Parkes 
on the Urine, p. 298). Much benefit is also derived from 
the continuous administration of salines in small doses, re- 
peated two or three times a day, in a very dilute form, and 
always on an empty or nearly empty stomach, and some lit- 
tle while before food (Garrod). If acute gout should have 



GOUT, CHRONIC. 167 

" retroceded," as it is called, and the stomach or intestinal 
canal be inflamed, leeches should be applied to the abdo- 
men or epigastrium, followed by a poultice, while the neutral 
salts, with the tincture of hyoscyamus, should be given at 
least every four or six hours. It is very rare that more act- 
ive medicines are necessary. 

For further indications regarding the management of gout, 
see treatment of the next subject — namely, chronic gout. 

GrOUtj Chronic. — Definition. — A persistent constitutional 
affection, characterized by stiffness and swelling of various 
joints, with deposits of urate of soda. 

Treatment. — In chronic gout the treatment is the same as 
in acute gout ; but, as next to hereditary predisposition, a 
disproportion between the amount of food and drink taken 
and the necessity for it, is a great cause of the disease, means 
ought to be taken to regulate the diet and promote healthy 
metamorphosis of tissue during intervals of freedom from 
gouty paroxysms. The habits of the patient ought to be 
regulated by written rules for him to abide by, if he would 
be free from gout. The form, the quantity, and the quality 
of the food ought to be precisely prescribed. Most gouty 
patients eat too much. Vegetables, with soups and meat, 
must be allowed only once a day — not oftener. Beer, wine, 
and alcoholic fluids generally are injurious, and must be for- 
bidden to gouty patients, as they retard the metamorphosis 
of tissue. The same is true of tea and coffee. Water, pure 
water only, taken in quantities as large as possible, promotes 
the metamorphosis of tissue to a greater extent than any 
remedies we know of. The drinking of a certain extra quan- 
tity of water is essential for the maintenance of health in 
gouty patients. It ought to be taken in the early morning — 
to the extent of half a pint while dressing in the morning — 
and before any solid food is taken. Its use does not lessen 
appetite for food — as is the case with beer, wine, spirits, tea, 
and coffee. It promotes the flow of fluid by the kidneys, 
and increases the excretion of urea. Combined with muscu- 
lar exercise, the use of pure water hastens, to the greatest 
possible extent, the transformation of tissue ; and combined 
with the use of certain mineral waters and baths, a connect- 
ing link is established between the dietetic and medicinal 
treatment of gout. Whenever an excess of lithic acid or of 
lithates is seen "in the urine, some alkaline water should be 
taken in the morning, instead of plain water ; and enough 
should be taken to render the urine clear and free from de- 



I 68 GOUT, CHRONIC. 

posit. But strong alkaline waters are not to be prescribed 
in large quantities, else too great depression and a tendency 
to impair the digestive power of the stomach will be the re- 
sult. In moderation, the milder alkaline waters taken as a 
morning draught are of value. The mineral springs which 
exercise the most favorable influence on the gouty constitu- 
tion are those of Aix in Savoy, Bath, and Buxton, Ems, Gas- 
tien, Homburg, Karlsbad, Kissengen, Marienbad, Neuenahr, 
Pfaffers, Schwalbach, Pyrmont, Spa, Toplitz, Wiesbaden, 
Wilbad, and Vichy. Dr. Garrod lays- down the following 
general rules as a guide to the use of them : — (i.) Their use 
should be prohibited when there is much structural disease 
in any important organ, especially in the heart or kidneys ; 
and even when organic mischief is slight, the greatest caution 
in their use is necessary. (2.) They are to be avoided when 
an acute attack is either present or threatening. (3.) The 
particular mineral water must be selected according to the 
nature of the individual case ; for the robust, and those of 
full habit, the alkaline saline springs should be chosen ; when 
torpidity of the bowels predominates, the purgative waters 
may be used ; when the skin is inactive the sulphur spiings 
should be used, and when much debility prevails, or an atonic 
state exists, then the more simple thermal springs may be 
prescribed. 

These waters contain either alkaline carbonates, chlorides, 
or sulphates. Some are impregnated with sulphurated hy- 
drogen, and others contain iron ; many, like Wiesbaden, 
Karlsbad, and some of the Vichy springs — Wildbad and 
Neuenahr — are of an elevated temperature. 

The beneficial influence of these natural mineral waters is 
especially perceptible in the reduction of plethora by the al- 
kaline springs, and in the regulation of the functions of the 
bowels and skin. The springs of Vichy are all rich in car- 
bonate or bicarbonate of soda — about forty grains to the 
pint. Some have a temperature of 101 Fahr. In moderate 
doses they cause the urine to become alkaline or neutral ; 
and used as baths, they have a similar effect. They influ- 
ence especially the functions of the liver and the skin, and 
are more adapted for the robust and persons of full habit of 
body ; but if the system is enfeebled by frequent attacks of 
gout, or if there is a tendency to the formation of chalk con- 
cretions, the waters of Vichy are not to be recommended. 
The waters of Wiesbaden contain a large amount of chloride 
of sodium, and areas high in temperature as 160 Fah_. 



GOUT, CHROXIC. I69 

They are more highly stimulating and more generally debili- 
tating than those of Vichy, and are of service in those cases 
where the circulation is slow and the secretions deficient. 
The springs of Neuenahr range in temperature from 90.5 ° to 
104 Fahr., and contain nearly 50 per cent., by volume, of 
free carbonic acid, with a considerable quantity of soda salts, 
chiefly as carbonates. They stimulate the circulation, aug- 
ment the excretions from the kidneys and the skin, increase 
the appetite, and diminish stomachal acidity. They are un- 
suitable for plethoric habits and where the liver is enlarged ; 
but where the constitution is impaired or enfeebled, they a^e 
of great service. The waters of Wildbad, in the Black For- 
est, have also a high temperature — 92 ° Fahr. — with much 
free carbonic acid, holding salts of soda, and magnesia, and 
iron in solution. They are alkaline, and their influence is 
similar to the springs of Neuenahr. The waters of Aix are 
slightly saline, and of a temperature as high as 135 Fahr., 
containing chloride, carbonate, and sulphide of sodium, with 
free sulphurated hydrogen. They stimulate the liver, kid- 
neys, and skin, and are indicated where there may be slug- 
gish action of these functions, and where the joints are stiff. 
The Karlsbad waters are rich in sulphate of soda, with car- 
bonate of soda and common salt. Their temperature is 
about 167 ° Fahr. They are purgative, diuretic, and diapho- 
retic, and are beneficial where there is constipation, with con- 
gestion of the liver ; and are unsuited for feeble patients. 
The waters of Baden-Baden contain common salt combined 
with iron, and are also rich in lithia. Toplitz, Gastien, Bux- 
ton, and Bath waters are also all somewhat elevated in tem- 
perature, and are peculiarly adapted for the treatment of 
gout in the infirm, feeble, and old patients. The chalybeate 
waters of Spa and Pyrmont are most suitable for anaemic 
patients and in the asthenic forms of chronic gout. The salts 
of lithia, so abundant in the waters of Baden-Baden, were 
originally proposed by Dr. Garrod as a remedy for gout. 
They have since been extensively used, and found generally 
beneficial. They abound also in the Karlsbad, Aix, Marien- 
bad, and some of the Vichy waters. The salts of lithia are 
actively diuretic, powerful solvents of uric acid, and generally 
they tend to render the urine neutral. Taken for a length 
of time in a dilute form, they tend to prevent paroxysms of 
gout in chronic cases, and cause soluticn and absorption of 
chalky matter. They certainly lessen the deposit of water 
and uric acid in the urine ; and are of service both in the 



170 GOUT, CHRONIC. 

acute and chronic forms of gout. The dose is from five to 
ten grains of the carbonate of lithia, dissolved in aerated 
water, three or four times a day ; of the citrate, eight, ten, or 
more grains may be given (Garrod, Flint, Clymer). Iodide 
of potassium is a remedy of very great value, especially in 
cases where " the pains are increased at night;" but the 
bromide of potassium is still more useful. It seems more 
highly anodyne and soothing. The iodide of potassium is 
useful in removing the recent thickening in the tissues round 
joints ; and of gouty inflammation, when fluid is effused into 
the cavities of joints, and is slow of absorption. Guaiacum 
is especially useful in the asthenic gout of old subjects, and 
to younger patients also it is beneficial. A combination of 
quinine, iron, and arsenic is often of special service, in very 
minute doses, in the form of chlorides ; and it is advatageous 
to unite small doses of colchicum with the quinine. 

The patient generally receives some warning by which he 
may try and ward off the gouty seizure. When such warn- 
ings are recognized a combination of quinine, colchicum, and 
colocynth, taken twice or three times a day, is an excellent 
medicine. The pills of Becquerel are also recommended by 
Trousseau. They consist of : — 

!>.. Quini?e Sulphatis, gr. xx. ; Ext. Digitalis, gr. iii. ; 
Ext. sem. Colchici, gr. x. Divide into ten pills, of which two 
or three may be taken daily for three or four days. 

Laville's anti gout liquid and pills are French preparations, 
and are so popularly known and so much esteemed by man)'- 
sufferers, who have used them with excellent effect, that they 
challenge attention, although they are open to the objection 
of being secret as to their composition, like chlorodyne, 
James' powder, and Warburg's drops. According to Dr. 
Tanner, " from an analysis, the liquid contains the active 
principle of colocynth, quinine and chinchonine, with unim- 
portant salts of lime. It is used at any period of the attack ; 
a teaspoonful being taken in sweetened water or tea, and re- 
peated in six hours, if the pain continue and the bowels be 
not moved. Twenty-four hours are to elapse before the next 
dose, when half the quantity is to be taken two or three times 
daily, unless the buwels are irritable. The pills consist of 
physalin mixed up with silicate of soda and powdered cham- 
sedrys." One is taken just before a meal, for several weeks. 
In the chronic forms of the disorder, where there is no or- 
ganic disease of the brain, heart, or lungs, wet-packing, and 
the Turkish bath, cautiously and occasionally used, but not 



GOUT, CHRONIC. 171 

during a paroxysm, under the immediate supervision of the 
attending physician, would sometimes seem to be of service, 
in lessening stiffness of the joints and restoring or improving 
the action of the skin (Clymer.) Trousseau speaks well of the 
wet-packing. Hot salt-water baths are also beneficial. The 
inhalation of oxygen when followed by clear urine, has also 
given great relief, and in some cases cures have resulted. 

In atonic gout some light tonic medicine may be given, as 
five to ten grains of the citrate of iron. A large number of 
chronic cases, however, though the general health is im- 
proved by this treatment, are often altogether unrelieved as 
to the local symptoms, and are often quite unable to assist 
themselves. In these instances the terebinthine remedies ap- 
pear to be beneficial, as spruce beer, and Canadian balsam ; 
or, one drachm of the oil of turpentine may be taken in an 
effervescing draught once or twice a day. Sydenham's 
method of treatment by manna may also be used. He re- 
commends, from experience in his own case, large doses of 
manna in all cases of what he terms "bloody urine." If the 
chronic or atonic gout should become retrocedent, and the 
stomach and intestinal canal be the seat of the spasmodic 
form of the disease, Sydenham strongly recommends that 
laudanum should be given ; but perhaps the following draught 
is more efficacious, namely — 

5, . Aquae Camphorae, 3 x. ; Sp. Athens Sulphurici, 3 i- ; 
Sulphatis Magnesiae, 3 ss. 

It will remove from the stomach any undigested matter 
which may remain as an irritating cause. This should be 
given every hour till the patient is relieved ; and while it is 
being prepared, hot brandy and water should be freely ad- 
ministered, or the spiritus ammoniae aromaticus, in doses of 
sixty minims, and hot cloths applied to the abdomen, as well 
as hot bottles to the feet. 

As indiscriminate feeding appears to have a great influence 
in the production of gout, so we expect the regulation of 
diet should have great influence in its removal. During the 
fit the diet should consist of slops and light puddings, and 
afterwards white fish, till the paroxysm has terminated. 
Chronic gout is so distressing that many persons are inclined 
to diet themselves with great strictness during the interval. 
Sydenham says that a milk diet, or drinking milk as it comes 
from the cow, or boiled, without adding anything to it, except 
perhaps a piece of bread, once a day, had been much used for 
twenty years past in his time, and had done much service to 



172 GOUT, CHRONIC. 

gouty patients. But on quitting it, and returning to the mild- 
est and tenderest diet of other persons, gout has immediately 
revived; and he adds, that many cannot bear this regimen. 
An entirely water regimen he considers hurtful. The most 
digestible meats, such as mutton, well-kept beef and poultry, 
with the white kinds of fish, as cod-fish, sole, and whiting, 
may be eaten; but salmon, veal, and pork are to be avoided, 
as well as cheese, salads, highly seasoned dishes, and rich 
sauces, or other " elaborate preparations on the part of the 
cook." The use of alcoholic stimulants requires great cau- 
tion. For those who inherit the gouty constitution, total ab- 
stinence should be made a rule absolute in youth; and for 
all others, unless some obvious necessity arises for their use 
and prescription by the physician, when the nature and 
quantity of the stimulant must be definitely stated, and meas- 
ured out as any other medicine would be. If alcohol in any 
form is required, it may be taken as weak brandy, gin, or 
whisky and water, or pure dry sherry, like Amontilado or 
Manzanilla. Port, Burgundy, and sweet wines must be 
avoided; but wines of the Rhine vintages may be taken, if 
they do not contain a large percentage of alcohol. The 
wine should be of the highest quality, and fully matured and 
mellowed. Really good wines are generally used to advan- 
tage, and the vegetable extractions of the pure, mature, and 
mellowed wines are easy of digestion by the gouty stomach. 
The best spirit is whisky, which should also be very old, soft 
and mellow, and free from the smoky flavor. All of these 
spirits ought to be taken much diluted with water. The pa- 
tient should go early to bed, keep the mind free from all dis- 
quietude, live with the greatest moderation, clothe himself 
warmly, and ride on horseback. When exercise cannot be 
taken, friction over the surface of the body is exceedingly 
useful. He should be rubbed down with a flesh-brush once 
or twice a day, just as a horse is groomed. Turkish baths 
taken regularly once a week, or as often as may be indicated 
by the medical attendant, are most beneficial. The custom 
of going to bed for an hour or two immediately after the bath 
— as in Germany — adds greatly to the good obtained from 
the bath; the body being covered and completely at rest, the 
nervous system is tranquillized, and the skin acts freely. But 
much harm may be done by excessive limitation of the sup- 
ply of nourishment, as well as by the sudden and complete 
abstraction of spirituous fluids that had been used for years; 
as well as by other debilitating courses of treatment set about 






GRAVES' DISEASE. 173 

too hastily and pursued too vigorously. If the patient is 
cachectic, debilitating treatment will make him worse. 
" There should be a due admixture of animal and vegetable 
food; it is an error to suppose that an animal diet tends more 
to the formation of uric acid than a vegetable one. The tor- 
toise, feeding on a simple lettuce, excretes a large quantity 
of urate of ammonia, far more in proportion to the weight of 
the animal than is excreted by the dog exclusively nourished 
with meat. Vegetables, as potatoes, greens, and the like, 
may be partaken of with advantage; the soluble salts they 
contain are of value in keeping up the activity of the secre- 
ting organs. The same remarks bold good with regard to 
soft fruits when eaten in moderation, as strawberries, grapes, 
and oranges; also other fruits when stewed or baked, as ap- 
ples and pears; but these latter, as likewise plums, and stone- 
fruit in general, should be avoided in a raw state. Extreme 
moderation should be exercised when saccharine fruits are 
eaten, as sugar is liable in many subjects to lead to the pro- 
duction of acidity. The same precaution is necessary in 
reference to the addition of sugar to other articles of diet." 
(Dr. Garrod). " Gouty folks should be very moderate in all 
their food — not, however, too abstemious, for such patients 
are seldom really vigorous, or able to dispense with a nutri- 
tious diet. Moderation should be observed, particularly in 
respect to the use of stimulants; and each patient must 
select for himself, or be advised to take what suits him 
best. There is a prevalent opinion that spirits are better 
than wines; but this is doubtful. The chief point is, that 
whatever stimulant is taken it should be used in the most 
strict moderation." (Sir James Paget). 

One other point with regard to the treatment of the patient 
during the fit is, that if it be necessary to move him, either 
on account of his restlessness or other cause, this should be 
done with great care and tenderness by the attendants; for 
although the pain may be latent while the parts are quiet, 
yet the least shock often causes the most excruciating agony. 
The irritable state of mind of the patient during the parox- 
ysm has been mentioned; and it is well known that slight 
moral causes will often produce a fit, while powerful emo- 
tions have sometimes cured one. It is quite essential, there- 
fore, that the minds of gouty patients should be kept as tran- 
quil as possible, both for their own sakes as well as for the 
comfort of those who minister to their needs. 

Grayes' Disease — See Goitre, Exophthalmic 



174 GREEN-SICKNESS HAEMATEMESIS. 

Green- Sickness— *SV<? Chlorosis. 

Haematemesis. — Definition. — A discharge of blood 
from the stomach. 

Treatment of the acute forms of haematemesis is similar 
in many respects to that of haemoptysis. The great volume 
of the arteries of the stomach, and their origin almost im- 
mediately from the aorta by means of the cceliac artery, are 
reasons which have been alleged for this affection being but 
little influenced by general or local bleedings. The vast 
amount of blood sometimes lost by haematemesis renders it 
necessary to support the patient by acid wines much sooner 
and to a much greater extent than in haemoptysis. In 
melaena the only chance for the patient is a liberal support 
by wine diet and medicines, and by opiates to quiet the 
stomach. In cases of haematemesis from cirrhosis, or other 
obstruction to the circulation through the liver, and in the 
vicarious haematemesis of women, leeches to the anal region 
or os uteri, are of service. The action of ice, by swallowing 
small pieces from time to time, is very beneficial, covering 
at the same time the epigastric region with ice-cold com- 
presses, which require to be renewed frequently. Solutions 
of dilute or aromatic sulphuric acid, in doses of ten to 
twenty minims, or of alum, are of service. Alum may be 
given in doses of eight to twelve grains, combined with 
Battley's solution of opium, or with laudanum or sulphuric 
•acid. In chronic haematemesis, acid, gallici, gr. x.; acid, 
sulph. dil., m x.; aq. distil., f 3 i., has been recommended by 
Dr. Brinton. Solution of pernitrate of iron, in doses of thirty 
to forty minims, may be of use. Ergot may also be of service. 
Tannin is of service, as one of the best astringents in the form of 
a pill (O. Rees) — three to six grains twice or thrice a day. 
The patient must maintain absolute rest in bed, and must 
not rise to stool. Ipecacuanha in doses to produce nausea 
is of service in arresting haemorrhage, and restoring heat to 
patients in the collapse of haematemesis (Osborne, Trenor, 
Graves), in doses of one to two grains every fifteen or 
thirty minutes till nausea is felt, when the remedy is to be 
discontinued, as vomiting is to be avoided. If stimulants 
are required, iced champagne may be given ; and when the 
vital powers are much depressed, amnion, hydrochlor., 3 iss.; 
acid, hydrochlor., f 3ss.; decoct, hordei co., oz. i., may be 
taken every second or third hour (Copland), in doses of two 
or three teaspoonfuls. 



HiEMATINURIA, PAROXYSMAL HEADACHE. I 75 

Haematiiiuria, Paroxysmal. — Definition. — A condition 
in which the urine contains only the coloring matter of the 
blood with albumen, but no blood-corpuscles nor fibrine, 
coming on in sudden and irregular paroxysms. 

Treatment. — Improvement has taken place under the use 
of saccharated carbonate of iron and quinine in full doses. 

Hematuria Renalis. — Definition. — Haemorrhages in 
which blood is mixed with the urine, whether it proceeds 
from the kidney, ureter, or bladder. 

Treatment. — Tincture of the perchloride of iron is one of 
the most useful of remedies, whether in debilitated patients 
or in those suffering from Bright's disease, and whether the 
blood comes from the kidneys or bladder. It is best given 
in doses of m x. to xx., three or four times daijy, in combin- 
ation with glycerine; and if there be much cardiac difficulty, 
with arterial excitement, it may be combined with digitalis, 
as in the following prescription: — 

5. Tinct. ferri perchloridi, m xxx. ; Tinct. digitalis, m 
xv.; Aq. menth. pip., f 3 iss., repeated every four hours. 

Gallic acid, in combination with sulphuric acid, may also 
be given ; as also ipecacuanha, tannin, acetate of lead and 
alum, and ergotine, as already referred to under Haemate- 
mesis. Quinine and arsenic are remedies indicated in 
malarious intermittent cases. Idiopathic haemorrhage often 
readily yields to bitartrate of potash, or to the mineral acids. 
Dr. Elliotson recommends, as also did John Hunter, the ol. 
terebinthinse, in doses of m x., m xx., or m xxx., every two, 
or three, or four hours. Injections of cold water (or water 
in which twenty to forty grains of alum have been dissolved) 
into the bladder or up the rectum, and also a cold hip-bath, 
are useful applications. Dry-cupping over the loins is also 
indicated. 

Haemorrhage, Cerebral or Spinal — See Apoplexy. 

Headache. 

Treatment. — (1) Of Sick-headache. — Looking to the true 
cause of sick-headache as one which lies deep in the pa- 
tient's idiosyncrasy, and as an affection which is developed 
by a hundred different sources of excitement, the advice to 
sufferers is to give as much tone as they can to their nerves 
by adopting all those methods which experience has shown to 
be good, and then avoid, as far as is practicable, all those causes 
which are known to excite an attack. Purgation has no good 
result. The only remedies which are of any avail are those 



176 HEADACHE. 

which act on the nervous system, such as hot tea and coffee ; 
or, after the stomach is quieter, and the more urgent symp- 
toms have passed off, a little wine or ammonia. If the head- 
ache take more the form of hemicrania, then other remedies 
are occasionally useful, as the local application of the bisul- 
phide of carbon, or galvanism, and internally the bromide of 
potassium. This is the only drug which Dr. Wilks has really 
seen to be serviceable. Whilst the nausea exists and the 
worst symptoms prevail, even this remedy is of no avail. As 
regards tea and coffee, which often relieve, it is possible that 
these and other stimulants, taken in excess, render the ner- 
vous system more susceptible to the attacks. 

In the treatment of the paroxysm nothing is so efficacious 
as complete rest in the recumbent posture, with warmth, in 
a perfectly quiet and darkened room. A cup of very strong 
tea or coffee has also given relief. A comparatively new 
drug — guarana — has also been recommended. A full dose 
of brandy, or of ammonia, has also sometimes dispelled the 
headache ; so has continued sipping of a solution of carbon- 
ate of potash or of soda. Pressure upon the carotid artery 
of the affected side sometimes also relieves the pain, but for 
a time only. Evaporating lotions, belladonna, or aconite 
ointment may also ward off or subdue the headache ; but, as 
a rule, time is the most efficient element, with warmth to the 
feet and to the body, and the induction of sleep. 

Adopting the theory of Dr. Latham, what are the indica- 
tions for treatment with which it supplies us — (a.) During 
the stage of disturbed sensation ; (b.) during the stage of 
headache ; and, (c) during the intervals between the attacks ? 
The following are the results of his experience : — 

{a.) During the Stage of Disturbed Sensation. — It is found 
that the longer this stage lasts, the greater will be the head- 
ache ; and therefore it is desirable to shorten it as much as 
possible. If the condition depend upon deficient supply of 
blood to a part, such means must be adopted as shall assist 
and increase the flow of blood to the part ; and this can be 
done in some measure by posture and stimulants. Directly 
the glimmering appears, the patient should lie down with the 
head as low as possible, and if the glimmering be on the right 
or left of the field of vision, he should lie on the opposite 
side. Let him take at once one ounce of brandy, either 
" neat " or in half a bottle of soda-water. Champagne would 
be preferable, being more diffusible ; but its administration 
would often involve a little delay. If alcoholic stimulants 



HEADACHE. 



177 



be objected to, or if it be not advisable to recommend them, 
then a teaspoonful of sal-volatile in water may be prescribed 
instead. If J \c patient be chilly or his feet cold, the couch 
should be drawn before the fire, a hot bottle applied to the 
feet, and his body eoverec over with a warm blanket or eider 
down quilt. By these means the heart is enabled to drive 
the blood with greater force to the brain, and the duration of 
the vibratory movement is thereby materially lessened. Af- 
ter it has passed off, the patient should lie still for a time, so 
that the glimmering :nciy not return. This injunction will 
only be necessary when the headache is slight; if it be severe, 
attended with much nausea or vomiting, the patient will be 
little disposed or able to leave the recumbent position. If, 
instead of the disturbance of vision preceding the headache, 
there be a feeling of depression or irritability (fidgets), the 
administration of such cerebro-spinal stimulants as henbane, 
valerian, assafcetida, spirit of chloroform, or ether, will often 
cut short the attack; ten or fifteen drops of the tincture of 
henbane, with the same quantity of spirit of chloroform, will 
soothe the nervous irritability in the slighter forms, and may 
be repeated in three or four hours, if necessary. If there be 
great mental depression, then valerian or assafcetida should 
be tried. Stille says, — " Nothing is more astonishing in the 
operation of remedies than the promptness and certainty 
with which a dose of valerian or assafcetida dispels the 
gloomy visions of the hypochondriac, calms the hurry and 
agitation of nervous excitement, allays commencing spasms, 
and diffuses a soothing calm over the whole being of one who 
but an hour before was a prey to a thousand morbid sensa- 
tions and thick-coming fancies of danger, wrong, or loss." 
Dr. Latham gives the preference to valerian, and prescribes 
from half a drachm to a drachm of the ammoniated tincture. 
Or it may be combined, as in the following formula, with 
bromide of soda; ammoniated tincture of valerian § iv. with 
3 vi. bromide of sodium, in teaspoonful doses every hour. 
The assafcetida may be given in the form of the spiritus 
ammonise fcetidus of the Pharmacopoeia, also in half drachm 
or drachm doses. As a rule, alcoholic stimulants are not 
advisable in this stage of the headache. A small quantity 
will cause flushing, heaviness, slight confusion of thought, 
&c, without relieving the depression; and though the severe 
headache maybe averted, alcoholic stimulants do not answer 
so well as the remedies previously mentioned. 

(b) During the Stage of Headache, — If the headache be 



178 HEADACHE. 

slight and the patient soon able to sit up, there is little to be 
done; a cup of coffee or tea, cheerful conversation, a walk, 
drive, or ride, may often help to remove the pain. If, how- 
ever, the headache and nausea be severe, then the adminis- 
tration of further remedies is called for. The patient should 
keep perfectly still and quiet, with the room darkened; for 
every sound or sight causes pain, and the slightest movement 
is sufficient to produce gastric uneasiness. Sometimes free 
evacuation of the contents of the stomach, especially if it 
contain undigested food, is followed by relief. Dr. Fother- 
gill says, — " An emetic and some warm water soon wash off 
the offending matter, and remove these disorders," which 
may be very well where there is any offending matter to wash 
off, but it is not very often that this is the case ; the nausea 
frequently continues long after the contents of the stomach 
have been discharged ; an inverted action of the duodenum 
is set up ; the bile appears in the fluids excreted ; the patient 
believes that all his troubles are due to "its overflow ;" " it's 
all liver," he says, and it is sometimes difficult to persuade 
him to the contrary. Generally, then, you should try to re- 
lieve and check the vomiting. Iced soda-water, with or 
without two or three drops of dilute hydrocyanic acid, or 
spirit of chloroform ; cold tea ; the effervescing citrate of 
potash, with hydrocyanic acid, may often afford marked relief. 
The headache may be lessened by applying cloths dipped in 
cold water, or evaporating lotions, to the head ; if the ex- 
tremities be cold and the headache severe, a warm stimulating 
foot-bath can be tried so soon as the nausea will allow the 
patient to sit up. If the attacks occur in the early part of 
the day, as soon as the pain has subsided it is generally better 
for the patient to sit up, or move about, or take exercise in 
the open air. During the attack the appetite is diminished, 
the idea even of food provoking disgust. Still, after the 
nausea has passed away and the headache has continued a 
few hours, a plate of hot soup or some easily digested food 
will often have a good effect in equalizing the cerebral circu- 
lation. A remedy which may very often be given with ad- 
vantage if the headache be severe, is bromide of potassium, 
in doses of five, ten, or fifteen grains, to which thirty or forty 
minims of sal-volatile may, in some cases, be added with ad- 
vantage ; and if the nausea still continue, these may be given 
in combination with the effervescing citrate of potash. A 
saline purgative at the commencement of an attack is some- 
times an effectual remedy ; but, as a rule, the use of purga- 



HEADACHE. 179 

tives is objectionable. So far, these measures are only palli- 
ative. 

(c.) During the Intervals between the Attacks. — First of all, 
the exciting cause is to be discovered and removed. Hours 
of study or work must be abridged; excessive bodily fatigue, 
loss of rest, everything, in fact, must be avoided which the 
sufferers know from individual experience will act as exciting 
causes. Where the attacks are associated Avith excessive 
mental work, they should be regarded as danger-signals, 
showing necessity for relaxation. The tone of the bodily and 
nervous systems must be improved by proper medicinal and 
hygienic means; and the chief remedies are steel, strychnine, 
phosphorus, and cod-liver oil. The success, however, fol- 
lowing these remedies depends a great deal upon the way in 
which they are administered. For a day or two after the at- 
tack the stomach and bowels may possibly be disordered, 
and not in a fit state to tolerate such remedies. This must 
first be corrected. The simple vegetable bitters, such as 
gentian, with small doses of henbane and some aromatic, may 
be of service; and, if necessary, one or two grains of blue 
pill, with four or five of compoudd rhubarb pill, maybe given 
at night. We may then try steel. In ansemic cases it may 
be advisable to stimulate the action of the heart, as by the 
following: — 

]$. Ammonise muriatis, § ss., Tinct. actseae racemosae 
aquae, a a 3 iii. Two fluid drachms for a dose after meals 
in a wineglass of water. 

If there be despondency with depression of spirits, phos- 
phorus to the extent of t Jq- to -gV °f a grain, combined with 
nux vomica or carbonate o£ iron, or both taken with each 
meal, will improve the tone of the patient. If the attacks 
have been frequent, or if there be any scrofulous tendency, 
the iodide of iron may be given in the folowing form: — 

r>. Ferri et amnion, citrat., gr. v.; potassii iodidi, gr. ij.; 
aquae, § j ; and, according to circumstances, fifteen to 
twenty minims of tincture of henbane or twenty or thirty 
minims of aromatic spirit of ammonia may be added. 

If the stomach be at all irritable, this medicine may be 
given in the effervescing form, adding to each dose twenty 
grains of bicarbonate of potash, and directing it to be taken 
with a tablespoonful of lemon-juice, or a corresponding 
amount of citric acid: the dose to be taken twice a day, 
about eleven and four. The effervescing from may soon be 
left off, and then to each dose may be added five minims of 



i8o 



HEADACHE. 



liquor of strychnise (omitting the henbane and sal-volatile, 
and continuing the iodide of potassium according as it seems 
to be indicated or not). In other cases, the citrate of iron 
and ammonia with strychnine may be given at the beginning, 
sometimes combined with infusion of calumba. The iron is 
indicated by the greater or less anaemia of the patient ; but 
the strychnine is a very important remedial agent in the 
disorder. In small doses it acts as a simple tonic, increasing 
the appetite and improving the digestion ; it dilates the ves- 
sels, and thus increasing the supply of blood, it augments 
the activity of the spinal cord (Harley). It promotes the 
capillary circulation, and therefore its use is advisable for 
persons troubled with cold hands and feet (Anstie) ; and if 
it fulfil these conditions, it is clearly indicated in this dis- 
order. Cod-liver oil also often acts very beneficially. " It 
has been found by experiment that great exertion and pro- 
longed labor can be endured without fatigue when starchy 
and fatty foods are alone eaten ; . and there is reason 

to think that cod-liver oil is more easily absorbed than other 
similar substances" (Ringer). "It improves the digestive 
process, increases the proportion of red corpuscles in the 
blood; and invigorates the whole nutritive function" 
(Wood) ; and it particularly sustains the energy of the brain 
during prolonged mental exertion. A gentleman in the 
foremost rank at the bar told Dr. Latham that whenever he 
was engaged in a jury-trial which was likely to tax his ener- 
gies to a greater degree than usual, the thing which best 
sustained him was a good dose of cod-liver oil taken in the 
morning before going into court ; and others engaged in 
mental work have confirmed this view. Besides its 
other properties cod-liver oil is a nutrient and tonic in its 
action on the cerebro-spinal nervous system. As a remedy 
for these nervous headaches, Dr. Latham prescribes it once 
a day, beginning with a small teaspoonful immediately 
after breakfast, and gradually increasin g the quantity to a 
tablespoonful, but not beyond, unless in exceptional cases. 

The action of the bowels must be regulated, but not by 
strong purgatives. Five grains of the Socotrine aloes pill, 
given at night, are generally sufficient. If the bowels be 
habitually constipated, then no remedy seems to answer so 
well as the aloes and iron pill. Five grains given twice a 
day, half an hour before meals, will act freely ; and in a few 
days the dose will have to be diminished, for its effect is 
augmented instead of being lessened by continual adminis- 



HEADACHE. l8l 

tration, especially when strychnine is given at the same time. 
The natural waters of Friedrichshall or Marienbad may, in 
many instances, be of service, given as laxatives. 

In 1872 Dr. Samuel Wilks, Physician to Guy's Hospital, 
directed the attention of the profession to guarana as a 
remedy for sick-headache, and at the same time asked for the 
experience of those who already had some acquaintance with 
the drug. His own knowledge of it dated about 1870, 
when, after the appearance of a lecture of his upon sick- 
headache, he received a letter from Mr. Helmcken, of British 
Columbia, inclosing two powders, which he recommended 
with much confidence as able to cure the complaint. " Upon 
my first headache after the receipt of Mr. Helmcken's letter, 
I took the powder, but with only doubtful effect. I there- 
fore did no more than casually mention the medicine to my 
friends, but did not recommend it. A few weeks ago, after 
the appearance of a second communication of mine in the 
journal upon the same complaint, I received a letter from 
Dr. Wood, of Montreal, in which he also recommended 
guarana as a remedy for headache, and gave a history of his 
own personal sufferings and the relief which he obtained. 
He says, — i By taking one of these powders and remaining 
quiet when I have felt premonitory symptoms by a beginning 
of pain always in the right temple (headache on the other 
side, or in any other part of the head, I never mind), I have 
carried off the attack ; and, with the first box, absolutely 
put it off for two months — something which had never 
occurred in my life before.' Upon so good an authority, I 
determined to try the remedy in a more systematic manner, 
and requested my neighbor, Mr. Hooper, the chemist, to 
procure me a packet of the powders. These I have recom- 
mended to several patients and friends ; and the result is so 
encouraging, that I have hastened to suggest their trial to 
my professional brethren. One lady speaks most enthusi- 
astically of their power, as she has now, on two separate 
occasions, had her headache arrested by their use. The 
drug has long been known, for mention is made of it in 
English and French pharmacologies, but appears never to 
have come into general use. It consists of the seeds of a 
tree growing in Brazil, called Paullinia sorbilis ; and these, 
according to Johnstone, in his Chemistry of Common Life, 
are used as we do cocoa. The seeds are ground into pow- 
der, and contain an alkaloid which is said to be identical 
with that found in tea and coffee. The medicine is manu- 



l82 HEADACHE. 

factured by Grimault & Co., No. 7 Rue de la Feuillade, 
Paris" (Wilks, Brit. Med. Jouni., April 20, 1872). 

The general outcome of experience regarding the treat- 
ment of sick-headache seems to be that, — 

(1.) Bromide of potassium, Indian hemp, Guarana or 
Paullinia powder, are remedies which have afforded relief. 
With reference to bromide of potassium, it is so valuable a 
medicine in many cases of sick headache that it can scarcely 
be superseded by a better remedy. The patient may have a 
splitting headache, fatigued and worried after a hard day's 
work. After fifteen or twenty grains of bromide of potas- 
sium, he presently goes off to sleep in his easy chair, and 
wakes in an hour well (Wilks). It is a medicine which Dr. 
Wilks always employs first, having seen such eminent ad- 
vantages follow its use. " I have known (he writes) many 
patients declare, that the bromide was the first medicine they 
had taken in their lives which had the slightest effect in re- 
lieving their headache." As to Cannabis Indica, it seems 
best adapted to the interval between the attacks, in doses of 
a few drops of the tincture, when headaches are recurrent. 
It is best given in ten-minim doses, three times a day, con- 
tinued for weeks or months (Wilks, John Murray). As to 
guarana powder, it seems most of all useful with females in 
arresting headache, so that it must be taken early when the 
headache is approaching ; and if headache is not arrested, a 
second dose should be taken in fifteen, twenty, or thirty 
minutes after the first. If the medicine is of use, the head- 
ache will have gone in about an hour. The dose is 15 grains 
of the powder ; and as it is somewhat astringent, it might be 
combined as an electuary with some laxative, such as the 
senna electuary (Hollis). 

(2.) Certain classes of cases ought to be distinguished from 
each other. There are two principal types : — the congestive, 
met with in dark or plethoric people, in those with consti- 
pated bowels and suppressed secretions, and those addicted 
to alcoholic beverages, or leading a monotonous sedentary 
life ; and that arising from exhaustion, whether from want 
of sleep or want of food, or great bodily or mental fatigue, 
strong emotions, &c. — this may be nervous, or asthenic, or 
anaemic in many cases. This latter form is very common in 
slight, delicate, and tuberculous females, and sometimes in 
the male sex. The treatment of these two forms must, of 
course, differ widely. An emetic or a purge in the one case 
will do what only rest, food, stimulants, and such medicines 



HEADACHE. 183 

as quinine, iron, opium, hyoscyamus and belladonna may 
afford in the other case (Dr. Bathurst Woodman). Rest and 
quiet, especially sleep, and abstinence from food, give relief 
and cure by a natural process of restoration. Generally, no 
relief is obtained till after a night of sound sleep — /. e., " one 
night through the sheets " — awakening next morning free 
from pain, but generally more or less depressed. If depres- 
sion continue, phosphorus with nux vomica in the form of 
sugar-coated or pearl-coated pills may be given to the extent 
of one-fiftieth of a grain of phosphorus and one-eighth of a 
grain of extract of nux vomica three times a day with food. 
Such despondency and depression are apt to occur in those 
who are over- worked mentally ; or who are harassed by busi- 
ness ; or who suffer great mental anxiety. If there be sleep- 
lessness, the following pill may be of use : 

^ Camphoras pulveris, gr. xx. ; Ext. Cannabis Indica, 
gr. xii. ; Ext. Hyoscyam., gr. xxiv., misce bene. Divide in 
pill xii. signa, one at night, to be repeated in two hours, if 
necessary, to procure sleep. 

As to local applications, a large sinapism over the stomach, 
followed by a warm linseed meal poultice, has sometimes 
been of service. If pressure relieves, the head may be bound 
round with a handkerchief. When the head throbs and is 
hot instinct seems to suggest cold and pressure to the part ; 
and one of the best external appliances on which we can rely 
to procure relief is the wet bandage tied tightly round the 
head. The method must be instinctive, for it is universal, 
and has been used from all time. Shakespeare is often 
quoted to illustrate the morbid states of the body as well as 
the passions of the mind, and he also testifies to this ancient 
practice. For example, in the scene between Huburt and 
Arthur in King John, the latter, when petitioning for the 
preservation of his eyes, says : 

" When your head did but ache 
I knit my handkerchief about your brows." 

And in Othello we have not only the remedy for headache 
given, but the cause. The former was the handkerchief about 
which the chief interest of the play" centred. 

" Desdemona, Why do you speak so faintly ? 
Are yon not well ? 

Othello, I have a pain upon my forehead here. 

Desdemona, Faith, that's with watching : 'twill away again. 
Let me but bind it hard, within this hour 
It will be well." 



184 HEADACHE. 

Sick-headache is not to be cured by gastro-hepatic reme- 
dies. It is a purely nervous affection, due to hereditary 
predisposition, and excited by causes innumerable which act 
on a susceptible nervous system. There is, then, no cure in 
the proper sense of the term, for this would imply a change 
in the patient's nature ; and for the attacks themselves, when 
severe, the only relief which can be reckoned upon is to be 
found in a wet bandage round the head, profound quiet, and, 
if possible, sleep (Dr. Bathurst Woodman). 

Considerable relief may be obtained from the use of cold 
applications, in the form of wet rags, ice in a bladder, or a 
little of the ether-spray ; but in not a few cases, after all, the 
best treatment during the attack is absolute rest and quiet, 
in a dark room, with warmth to feet and body, total absti- 
nence, except perhaps from fluids (hot and alkaline) in small 
quantities at a time ; to go to bed at once, and refrain from 
the use of any remedies. 

In a lecture on the therapeutics of headache, delivered at 
Bellevue Hospital Medical College, Dr. A. A. Smith sug- 
gests certain combinations of remedies which he has found 
of service in certain forms of headache : (1.) Malarial 
headache, where the pain is most frequently located in the 
sub- occipital or frontal regions, or on either side — hemi- 
crania. If distinctly periodical, give ten or fifteen grains of 
quinine two or three hours before the expected attack. It 
may be necessary to push the quinine in divided doses until 
cinchonism is produced, and kept up for several days. Then 
gradually diminish the dose. If the pain still continues to 
recur, resort to arsenic and belladonna, five-drop doses each 
of Fowler's solution and belladonna tincture, after meals, in- 
creasing the Fowler's one drop each day, until oedema arse- 
nicalis is produced. This will seldom fail to give relief. 

(2.) In Headache dependent on Gout : 

3 Vini colchici seminum, 3 iij. *, Lithii bromidi, 3 ss. ; 
Syr. zingiberis, 5 ss. ; Aq. cinnamonii, q. s. ad § vj. ; M. 
Sig. § ss. in a tumbler of Vichy water every four hours. 

(3.) Rheumatic Headache is characterized usually by ten- 
derness of the scalp, which is increased on pressure or mo- 
tion. Use the mild Faradic current on the scalp, and in- 
ternally the following : 

]J Potassii iodidi ; Ammonias muriatis, aa 3 jss. ; Infusi 
humuli, I vj. ; M. Sig. § ss. four times a day in a wineglass 
of water. 

In cases which have not yielded to the above treatment, 



HEADACHE. 185 

bromide of ammonium in twenty-grain doses every two hours 
may be effectual. 

(4.) Ursemic headache is of great importance as a symp- 
tom of serious disease. The pain in the head may be the 
first evidence that there exists renal disease, and that we 
have to deal with uraemic headache. The judicious plan of 
treatment in such cases is to call into action one or all of the 
three great emunctories of the body, the kidneys, the intes- 
tines, and the skin. To make the kidneys act, apply dry 
cups over the region of them, and give internally the fol- 
lowing : 

]J Potassse acetatis, 3 vj. ; Infusi digitalis, 3 vj. ; M. Sig. 
3 ss. every third hour. 

The infusion should be made from fresh English leaves. 
Give this until the kidneys act freely, if you can make them 
do it within twenty-four hours. If the kidneys do not act 
freely, and the headache be not relieved within twenty-four 
hours, give a saline cathartic. A treatment almost domestic, 
and often very effectual, is to put an ounce of cream of tar- 
tar in a quart of water, and have the patient drink this in 
eight or ten hours. It acts both as a diuretic and cathartic. 
Do not use hydragogue cathartics unless convulsions be 
threatened. Some prefer elimination by the skin. This can 
be done by diaphoretics and the hot, moist, or dry air bath. 
Diuretics, cathartics, and diaphoretics are only to be used 
where there is deficient quantity of urinary secretion. There 
are other causes of headache in Bright's disease which occur 
independently of the presence of an abnormal amount of 
urea in the blood, and which yet are dependent on the results 
of the kidney-disease. These causes may be anaemia, 
neuralgia, oedema of the brain itself, serous effusion into the 
ventricles ; and, in acute Bright's disease, cerebral conges- 
tion. Under the last condition, if the headache be very se- 
vere and convulsions threaten, blood may be taken if the 
patient's condition will admit of it, from twelve to twenty 
ounces, if necessary to relieve distressing symptoms. The 
best way to take it is by means of wet cups over the region 
of the kidneys. If the headache be dependent on serous ef- 
fusion into the ventricles, or on cerebral oedema, improve the 
vitiated condition of the blood, and stimulate the heart and 
kidneys by acetate of potash and infusion of digitalis. 
There is apt to be general anasarca with this effusion and 
oedema. 

(5.) The Headache of Acute Alcoholism, or inebriety. 



1 86 HEADACHE 

The first indication is to remove the alcohol from the intes- 
tinal canal. For this, give of rhubarb and magnesia calcined 
each a half drachm, and then the following: 

J$, Spiritus ammonise aromat., 3 ij- ; Tincturse camph., 
3jss.; Tincturse hyoscyami, 3 ijss. ; Spiritus lavandulae 
comp., q. s. ad J ij.; M. Sig. 3j. every hour until the head- 
ache is relieved, and then give capsicum gr. ij, and quinine 
gr. iij. before each meal for several days. If there be sleep- 
nessness give r}, Sodii bromidi, § ss. ; Chloral, hydrat., 3 ijss.; 
Syrupi aurantii cort., 3SS.; Aquas, 3 iijss. M. Sig. § s.'s. at 
night; repeat in two hours if necessary to produce sleep. 

(6.) Dyspeptic Headache. — If there be indigestible food m 
the stomach, and it have been there some time, give an 
emetic, as mustard and warm water, or sulphate of zinc s gr. 
xv. If there is evidence of indigestible food in the aliment- 
ary canal beyond the stomach, give gr, xx. of rhubarb and 
magnesia each, to remove it from the bowels. If the head- 
ache be frontal, and the pain be located immediately over 
the eyes, give dilute nitro-muriatic acid in ten-drop doses, 
well diluted after meals. If the pain be located about the 
roots of the hair, give an alkali before meals, as gr. 
xv. of bicarbonate of soda or magnesia. The dyspeptic 
headache oftentimes is not confined to these regions, but 
spreads over the entire head. In such cases combine an 
acid with an alkali, and add to these mix vomica, as in the 
following prescription: 

5. Sodae bicarbonatis, 3 ijss.; Acidi nitro-mur. diluti. 
3ij.; Tinct. nucis vomicae, 3 jss. : Syr. aurant. cort., 3vj.; 
Aquae, q. s. ad 3 vj. M. Sig. 1 ss. after meals in a wineglass 
of water. 

If there be gastric pain, a mild counter-irritant, as a mus- 
tard plaster to the epigastrium will often relieve the pain in 
the head as well as the pain in the stomach. If flatulence 
be a troublesome symptom, give the following: 

I£. Bismuthi subcarbonatis, 3 ijss. ; Tinct. nucis vomicae, 
3 jss.; Tinct. cardamomi comp.; Spiritus lavandulae comp. 
aa q. s. ad 3 iv. M. Sig. 3 ij. before meals in a wineglass 
of water. 

If there be constipation, the following pill may be given, 
in the morning: 

I£. Aloes pulv., 3 ss.; Ext. nucis Vomicae, gr. v.; Ext. 
belladonnas, gr. iv. ; M. Div. in pilulas, xv. 

In some forms of headache associated with stomach in- 
digestion, small doses, often repeated, of tincture of mix 



HEADACHE. 187 

vomica may be effectual. A single drop every fifteen minutes 
and continue this two or three hours if necessary. In other 
cases, where the headache comes on soon after a meal, 
and seems to depend on delayed stomach digestion, large 
doses of pepsin are effectual. Give a half drachm of sac- 
charated pepsin in a wineglass of sherry wine, three times a 
day, and let it be taken during meals. 

(7.) Congestive Headache — Cerebral congestion as a 
cause of headache may be divided into two varieties, active 
and passive. These demand almost directly opposite plans of 
treatment. In the active variety the patient should be kept 
in a darkened room, perfectly quiet, and have cold and evap- 
orating lotions applied to the head. A saline cathartic may 
be given ; and the following prescription : 

%. Sodii bromidi, 3 ijss, ; Fl. ext. ergot., 3 ijss. ; Syr. 
zingib., 3 ss. ; Aq.. aurant. flor. q. s. ad 3 iv. M. Sig. 3 ss. 
every two hours. 

If the skin be hot and dry, and the pulse full and rapid, 
give two drops of Fleming's tincture of aconite root every 
two hours, until the heart's action is sensibly diminished. 
Sometimes also a hot mustard foot-bath will give relief. 
The passive congestive variety demands a different mode of 
treatment. It is often found associated with cardiac dis- 
ease, and most frequently where there is predominant dila- 
tation. Hypertrophy gives rise to the active variety. Im- 
prove the condition of the blood by the use of iron, qui- 
nine, bitter tonics, alcoholic stimulants, good food, and stim- 
ulate the heart's action by the use of the following : 

5,. Tinct. digitalis, 3iij-, Spirit, arara. aromat., 3vj.; 
Spirit, lavandulae comp. ; Syr simp., a a q. s. ad 3 iij. M. 
Sig. 3 j. every four hours. 

(8.) Anoemic Headache. — Cerebral anaemia produces a 
headache which is often mistaken for the passive cerebral 
congestive form. It is associated with general anaemia, ner- 
vous exhaustion, and may occur in heart disease, in con- 
sequence of enfeebled heart power, such as is met with in 
enlargement with dilatation, fatty degeneration, and myo- 
carditis. Improve the general condition of the patient, and 
stimulate the heart's action as recommended in the passive 
cerebral congestive variety. Nitrite of amyl will relieve the 
immediate headache. Let the patient inhale three to five 
drops of it on a piece of cotton, placed within one nos- 
tril, while the other is held closed. When associated with 
nervous exhaustion, employ the following remedies : 



l88 HEART, FATTY HEART, HYPERTROPHY OF. 

]J. Strych. sulph.. gr. ss. ; Tinct. ferri chloridi, 3ij..; Gly- 
cerinae, Jss.; Infusi gentian., q. s. ad 5 vj M. Sig. 3 ss. 
after meals, in a wineglass of water. 

Alcoholic stimulants are beneficial in headache dependent 
on cerebral anaemia. Champagne as a remedy, and not as a 
beverage, may be given to those who suffer from nervous 
exhaustion , or a tablespoonful of brandy, diluted with 
water, after each meal. 

(9.) Cerebral Tumors give rise to headache, often severe. 
In all such cases, give iodide of potassium ; for it cannot 
be safely said that in any given case the tumor does not de- 
pend on syphilis, and by administering the remedy, the pa- 
tient gets the benefit of the doubt. 

There is reason to believe, too, that patients with cerebral 
tumors, dependent on other and unknown causes, are bene- 
fited by the use of iodide of potassium. If there be 
much sleeplessness, use the bromide and chloral mixture 
Ergot has also been used. It is usually given in large 
doses, beginning with 3 i. of the fluid extract thiee times 
a day, and gradually increasing the dose to half an ounce 
(New York Medical Record and London Medical Record 
Sept. 15, 1876.) 

Heart, fatty and other Degenerations of the. — 

Definition. — A change in the muscular substance of the 
heart, which results in elements of the muscular fibers being 
replaced by molecular fatty particles. The change tends to 
sudden death by rupture of the heart, or by syncope. 

Treatment — Iron in its various forms, quinine, and min- 
eral acids, are the medicinal agents suggested by the nature 
of this disease. Freedom from anxiety, thorough repose of 
mind, entire avoidance of fatigue, gentle but regular exercise 
in the open air, careful attention to the state of the skin, with 
a generous and nutritious diet at regular intervals, in moder- 
ate and equable amount at each meal, are the main hygienic 
indications calculated to impart tone to the system, improve 
the condition of the blood, and induce a more healthy nu- 
trition of the heart (Fuller). A salt-water sponging bath 
should be used daily. In cases where digestion is sufficient, 
cod-liver oil, cream, and mnk may be given with great ad- 
vantage (Tanner). The bowels should be so regulated as to 
render straining at stool unnecessary. 

Heart, Hypertrophy of. — Definition — An abnormal 
growth of the muscular substance of the heart, increasing its 



HEART, HYPERTROPHY OF 189 

volume by thickening of the cardiac walls; and generally 
with dilatation of its cavities. 

Treatment. — As the bad symptoms in valvular affections 
arise from defective compensation, and as the compensation 
depends on the integrity of the heart-muscle, the mainte- 
nance of its nutrition is of prime importance. Palliative 
treatment is necessarily directed to aid the mechanism by 
which the ill-effects of valvular incompetency are to be met. 
In affections of the aortic valves, when the heart-muscle is 
well nourished, an almost perfect compensation may be main- 
tained for years upon a nutritious (albuminous) diet, with 
fluids in small quantity — tonics, especially preparations of 
iron, being indicated. In the earlier stages a moderate 
amount of exercise is beneficial. In mitral affections, the 
compensation can never be so complete as to do away with 
the tendency to pulmonary complications. While the same 
nutritious diet and tonics are indicated to promote the nutri- 
tion of the cardiac muscle, exercise must be taken more cau- 
tiously; the object being to regulate and moderate the action 
of the heart, to control the tendency to local congestion, and 
to mitigate or remove the symptoms which result from the 
cardiac derangement. 

Any blood-letting required ought to be effected by the ap- 
plication of a few leeches to the precordial region, and very 
general relief will be obtained by hydragogue purgatives, 
aided by dry-cupping, mustard poultices, and turpentine fo- 
mentations. When, however, active congestion of the lungs 
exists, venesection, cupping, blisters, and sinapisms may be 
necessary. The distress from simple hypertrophy may, in 
the majority of cases, be greatly mitigated by such means as 
tend to tranquillize the action of the heart. No known drug 
possesses the power of controlling the growth of the heart. 
Saline and aloetic purgatives aid the calmative influence of 
the local abstraction of blood. Diuretics are useful inde- 
pendently of the existence of dropsy. Sedatives of the 
heart's action are indicated throughout, such as hydrocyanic 
acid, acetate of lead, digitalis, belladonna, and aconite, in the 
form of the alcoholic extract, given in doses of one-eighth of 
a grain (Walshe). It is chiefly useful in excessive hypertro- 
phy, with hydrocyanic acid and caffeine. In repeating the 
doses, the effects must be watched, while they relieve the 
painful sensations and disquietude about the heart. If anae- 
mia prevails, animal food should be permitted; and the more 
soluble and less astringent preparations of iron should also 



I90 HEART, HYPERTROPHY OF. 

be given. 'Fluids must be taken in small quantities. Like 
hypertrophy, dilatation of the heart is not removable by 
treatment. To improve the tone and strengthen the action, 
of the heart, without exciting its irritability, are the objects 
to be aimed at in the management of cardiac hypertrophy 
with dilatation. For this purpose the beneficial influence of 
digitalis has been ably shown by Dr. J. M. Fothergill, in his 
"Hastings Prize Essay" for 1870, published in the British 
Medical Journal, commencing July 1, 1871; and also by Dr. 
Balthazar Foster in the Medico-Chirurgical Review ioi July, 
1871. It is an efficient agent in helping to co-ordinate, by 
restoring the regularity of the heart's movements, when 
they have become tumultuous and irregular. The mechan- 
ism of compensation in each form of valve disease, therefore, 
requires to be considered. In hypertrophy digitalis is 
only of use when hypertrophy exceeds the limits of com- 
pensation. It slows the pulse and regulates the heart' 
muscle; but if the heart-muscle is unsound it will not be 
of service. As a general rule, the drug is most useful in 
mitral affections, and is contraindicated in aortic valve 
disease, except in cases in which the hypertrophy has ex- 
ceeded the limits of compensation, and become the chief 
cause of the symptoms. It slows the pulse and increases 
its tension while strengthening and regulating the heart's 
action. The slowing of the pulse increases the period of 
ventricular diastole — that is to say, the period during which 
regurgitation takes place when the aortic valves are incom- 
petent ; consequently, digitalis does harm in this lesion by 
augmenting the regurgitation. In mitral obstruction it is 
most valuable when the rapid, irregular pulse tells of the 
varying quantities on which the ventricle contracts. Some- 
times the interval between the ventricular contraction is so 
short, and the ventricular charge is so small, that the systolic 
wave does not reach the wrist. Under these circumstances 
the auricle must have more time to fill the ventricle. This 
is what digitalis effects ; for by slowing the action of the 
heart, the period of time during which the blood from the 
distended auricle can flow into the ventricle is increased ; 
and as the extra time allows more blood to pass through 
the narrowed mitral orifice before the final effort of the 
auricle is made, that effort is made on a smaller quantity of 
blood, and is consequently more effective ; for the smaller 
the quantity of blood which the auricular muscle has to push 
before it, the greater will be the velocity given to the cur- 



HEART, HYPERTROPHY OF. 191 

rent. The ventricle, through contracting less frequently, 
contracts more effectually. Instead of eighty or ninety 
irregular contractions per minute, we get some sixty steady 
equal beats. The pulse grows in force, fullness, and regu- 
larity ; the arterial tension rises ; the pulmonary congestion 
diminishes ; the kindeys, before inactive, wake up to their 
work ; and the advancing dropsy subsides (Foster, Med.- 
Chir. Rev.. July, 187 1). Digitalis is also most useful in mi- 
tral regurgitation. In place of a large number of ineffective 
contractions, it concentrates the power of the ventricle on a 
smaller number of well-directed steady beats, each throwing 
a larger charge of blood into the arteries, and so diminish- 
ing, beat by beat, the over-distension of the right heart. It 
may be prescribed as an infusion or tincture, and continued 
as long as the quantity of urine increases or keeps up to the 
maximum which the digitalis produced. Such diuretie effect 
is the outward or visible sign of its beneficial action. The 
high-colored scanty urine, loaded with urates, is then replaced 
by a clear and copious stream, which tells of a steadily-beat- 
ing heart and a firmer pulse (Foster). The tincture is the 
most convenient form for continuous administration (m v. to 
m x., three or four times a day). The freshly-made infusion 
acts most rapidly ( 3 ss. to 3 i., three or four times a day) 
along with potash or diuretics, and is conveniently added to 
vegetable infusions. Where it is desired to keep up the 
action of digitalis for a long time, the powder of the leaves 
is the most desirable form. It can then be given in pill, 
with the dried sulphate of iron, carminatives, laxatives, or 
both, twice a day. Half a grain to a grain of powdered 
digitalis, with an equal quantity of sulphate of iron, and a 
small portion (i of a grain) of cayenne pepper, in extract of 
gentian or aloes and myrrh pill, is a useful form which 
may be continued for months. This pill should be taken 
shortly after food. The addition of iron to digitalis is of 
great importance. The absorption of digitalis through the 
skin, by using poultices of the leaves, or flannel cloths soaked 
in the infusion and laid over the skin of the abdomen and 
thighs, is often most beneficial where it cannot be given by 
the mouth (Christison, Trosseau, Fothergill). 

There are some circumstances, however, under which it is 
necessary to withhold the administration of digitalis in car- 
diac disease — namely (1.) The presence of atheroma (endo- 
carditis) to any appreciable extent, and in aortic valve dis- 
ease. (2.) Reith, Gull, and Brunton object to its use in 



I92 HEART, HYPERTROPHY OF. 

fatty heart. (3.) Intermittency of pulse is also a contraindie 
cation. If that symptom comes on during its use, the fur- 
ther administration of digitalis must be suspended, mor- 
especially if the pulse becomes thready, and the quantity of 
the urine diminished. On the other hand, where intermit- 
tency is shown to be the result of the heart's inability and 
distress, the quantity of digitalis must rather be increased 
(Fothergill). (4.) The occurrence of persistent vomiting or 
noises in the head under its use, suggests that it should be 
left off, for a time at least. 

The action of the heart is also markedly influenced by 
veratrum viride. The dose of the tincture (from five to 
twenty minims) should be gradually increased from the 
smaller to the greater dose, till some obvious effects are pro- 
duced. If the pulse is reduced, or nausea occurs, no increase 
of the dose should be made. If vomiting occur, it should 
be suspended ; and when resumed, the dose should be dimin- 
ished. Veratria may be given in doses of from one-sixteenth 
of a grain to half a grain. When the pulse is sufficiently 
reduced, the doses should be diminished one half. Mor- 
phine or laudanum, with brandy, is an antidote for an over- 
dose of veratria, which is an exceedingly powerful remedy 
as a cardiac sedative, and requires to be used with 
great caution, the patient being constantly watched. Its 
depressing effects on the circulation and nervous system are 
often very striking — a pulse of 75 or 80 being reduced in 
the course of a few hours to 35 or 40 (Record of Pharmacy 
and Therapeutics, No. V., p. 35, J. C. Braithwaite). Sleep- 
lessness being one of the most distressing symptoms, opium 
in some form might be considered advantageous ; but " to 
give sedatives in such cases would be the refinement of cru- 
elty. What keeps the patient awake is not a want of ten- 
dency to sleep, but a condition that makes sleep impossible. 
Relieve him of his orthopnoea, and he would be asleep in ten 
seconds, and so dead asleep that it would take a great deal 
to rouse him, like a half-asphyxiated child on whom trache- 
otomy had just been performed. His great struggle is the 
struggle between sleep and life ; with opium thrown into the 
scale of sleep, the struggle for life would only be so much 
the harder. Only in one way would opium give him ease ; 
the narcotic of opium, added to the narcotic of the carbonic 
acid already circulating in his veins, might accelerate by 
some hours, or even days, the final coma, and make him 
sooner sleep the sleep of death. But the euthanasia that is 



HEART, HYPERTROPHY 01'\ I 93 

purchased by anticipating the natural process of death 
comes very near to homicide, and is an alternative that few 
would adopt " (Hyde Salter, Brit. Med. Journal, Feb. 8, 
1862). Morphia given hypodermically is the best form for 
relieving the dyspnoea and sleeplessness of some valvular 
affection?, especially in mitral valve disease. The dose to 
commence with is one-eighth to one-sixth grain of the bi- 
meconate of morphia (Dr. Clifford Allbut). But all seda- 
tives require the utmost caution in their use. 

The groundwork of medicinal remedies consists in the 
administration of general tonics in the form of bitters, min- 
eral acids, and preparations of iron. Belladonna may be 
employed to tranquillize undue excitement with greater 
safety than any other sedative remedy. A plaster of bella- 
donna and conium over the heart is of signal service when 
pain is usually felt near the apex, associated with palpitation. 
Due action of the bowels must be daily obtained, to accom- 
plish which the aloetic medicines are the best, aided by the 
gentle action of an occasional mercurial aperient. 

Careful regulation of the patient's mode of life is above 
all things necessary in diseases of the heart. Excitement 
of all kinds must be avoided ; and the diet should be light, 
nutritious, and of moderate quantity ; the clothing warm, 
and cold should be carefully avoided, especially by those 
affected with mitral disease. 

When anasarca supervenes, the bydragogue cathartics are 
required to insure copious watery discharges from the bow- 
els. Electuary of bitartrate of potash, or of gamboge, ela- 
terium, podophyllin, and compound jalap powder should be 
given on alternate days. Stimulants also may be required, 
the most suitable being Holland gin, or whiskey. 

When dropsy appears, diuretics yield most relief. Ace- 
tate, nitrate, iodide, and bitartrate ol potass, nitric aether, 
compound tincture of iodide, the infusion and spirits of 
juniper, or gin, may all be employed in successive changes, 
variously combined. Small doses of blue pill and compound 
squill pill at bedtime, will facilitate their action generally ; 
and so will cupping over the region of the kidneys, if symp- 
toms of congestion of these organs prevail. Hydragogue 
cathartics aid the diuretics in subduing the dropsical effu- 
sions, such as elaterium, gamboge, bitartrate of potass, and 
compound jalap powder — the two last made into an elec- 
tuary. 

T 3 



194 HEART, MALFORMATIONS OF PALPITATION OF. 

Heart, Malformations of. — Definition. — Deviations 
from the normal development of the heart, occurring in the 
earlier periods of gestation, and before the termination of 
fcetal life. 

The treatment of malformations which are associated with 
cyanosis is mainly preventive of dyspnoea and palpitation, 
by the avoidance of fatigue and mental excitement, the 
maintenance of temperature, and especially by a nourishing 
diet and warm clothing. 

Heart, Palpitation of. — Definition. — Palpitation and 
irregularity of the action of the heart, unconnected with or- 
ganicmis chief, beyond, in some cases, a notable hypertrophy. 

Treatment. — During the paroxysm the patient should lie 
flat on his back, bare his neck and chest, and allow the air 
to blow freely over him. The best remedies are, camphor 
mixture and aether, 3 i., with some slight opiate, as the syr 
up of poppies, 3 j., or tinct. hyoscyami, m xx. These 
should be repeated every quarter, or every half hour, or 
hour, according to the severity of the attack, till the heart's 
action is soothed. Cold brandy and water may be a substi- 
tute for, or adjuvant to, such medicines. If the attack oc- 
curs shortly after a meal, some purgative should be given 
to clear the stomach and bowels. Bicarbonate of potash 
(in io to 20 grain doses) is then also an excellent stimulant 
as well as antacid and sedative. Leeches to the os uteri in 
females, and to the perineum in males, sometimes relieve 
palpitation — proceeding in the one case from uterine dis- 
turbance, or from varicose veins, hypochondriasis, or hepatic 
congestion in either sex. Bromide of potassium and ammo- 
niated tincture of valerian are also indicated. Digitalis is 
useful under the following conditions : — (a.) When there 
are palpitation and acute depression of the heart's action 
from shock (Paralysis of the sympathetic of Romberg), 
marked by a small feeble pulse, coldness of skin, cold breath, 
diminished temperature, and evidence of the organic system 
of nerves being acutely depressed. The heart's walls con- 
tract ineffectively. It does not respond to the stimulus of 
its contents. Combined with other stimulants, the adminis- 
tration of digitalis in a case of shock, following parturition, 
was followed by the most satisfactory results (Drs. Fother- 
gill and Wilks, Med. Times and Gazette, Jan. 16, 1864). In 
Dr. Wilks' case, the patient seemed to be in articulo mortis 
— the face livid, no pulse at the wrist, and a mere fluttering 



HEMIPLEGIA. 1 95 

heard over the region of the heart. Brandy and ether had 
been given with no result ; and dissolution being imminent, 
it was determined to administer digitalis, of which half- 
drachm doses of the tincture were given every hour. After 
four doses reaction took place, and after seven doses com- 
plete recovery occurred. The full veins and condition of 
the heart indicated distension and paralysis (Fothergill, 
Brit. Med. Journal, July 29, 187 1.) (b.) When there is the 
irregular action of cardiac asthenia, (c.) When there is pal- 
pitation in dilated heart. It is useful to continue the medi- 
cines which have been mentioned, but at longer intervals, 
for some time. It is important also to counsel the patient 
strictly as to diet. It is often found that the palpitation re- 
turns after tea or after breakfast, or whenever hot tea or hot 
coffee has been drunk. In these cases it is desirable to 
avoid all hot slops, and to drink cold water at breakfast, and 
indeed at every meal. There are few tonics so beneficial as 
the natural tonic of cold water ; and persons once accus- 
tomed to it feel a return to a modern breakfast a punish- 
ment rather than a gratification. Wine should not be taken, 
unless largely diluted with water, to be prescribed as required. 

Hemiplegia. — Definition. — A form of paralysis affecting 
one lateral half of the body. 

Treatment. — The object to be aimed at in the early treat- 
ment of hemiplegia is to keep down the frequency and force 
of the heart's action. For this purpose strict maintenance 
of the horizontal position is necessary ; and when concious- 
ness exists, let the mind be kept tranquil by every means. 
Remove any local impediment to the easy flow of blood, and 
let the head be slightly raised, in a room of equal tempera- 
ture. Let the bowels be cleared out, so that no irritation 
from them may operate injuriously on the brain. Enemata 
ought to be employed ; and castor oil or calomel, with com- 
pound jalap powder, may effect an efficient evacuation. 
Food should be nutritious and easy of digestion, and not too 
abundant. 

The gradual removal of blood may be of service by re- 
lieving congestion of the right side of the heart, as shown by 
engorgement of the veins of the head and neck, and by livid- 
ity of surface (Bristowe, Watson). The circumstances under 
which its use is inadmissible are thus defined by Dr. Todd : 
If the patient be cold and collapsed ; if the heart's action be 
feeble and intermittent ; if there be an anaemic state ; if the 



I96 HEMIPLEGIA. 

patient be of advanced age ; if their is evidence of exten- 
sive disease of the arterial system or of the heart ; or, lastly, 
if it can be ascertained that already a large amount of 
haemorrhage has taken place into the brain ; — these, singly 
or conjointly, are reasons why bleeding ought not to be re- 
sorted to. If none of these objections exist, it is to be con- 
sidered whether any of the indications noted require to be 
fulfilled, and whether they can be fulfilled by a local or gen- 
eral blood-letting. Modern investigations show that the 
brain is not generally in a hyperaemic state ; so that it is 
chiefly to check or to prevent haemorrhage that bleeding is 
to be resorted to in such cases. The sudden or rapid ab- 
straction of a moderate quantity of blood, either from the 
arm or temple, or by skillful cupping, may check haemor- 
rhage, but the quantity taken should be small ; and so, like- 
wise, the quantity drawn ought to be moderate, if it is de- 
sired merely to lessen the frequency and force of the heart's 
action. " Generally, Dr. Todd came to the conclusion that, 
in cases of white softening, you are less likely to err by 
omitting than by adopting the practice." The rigidity of 
the muscles, which comes on very early and which indicates 
an inflammatory process going on round the clot, is to be 
combated by urinary and alvine evacuants, and by counter- 
irritation. It is not desirable to interfere in the later forms 
of muscular rigidity. With regard to the use of expedients 
for promoting the restoration of the paralyzed limbs to their 
normal condition, Dr. Todd's experience led him to write 
that nothing is of more decided benefit than a regulated 
system of exercise — active when the patient is capable of it, 
passive when he is not. , 

Any congestion of the spinal cord apt to supervene on 
cerebral hemiplegia must be diminished. The patient should 
not lie on his back, but, if possible, flat on his belly, the 
arms and legs being encased in flannel, and placed at a lower 
level than the spine. A hot douche may also be applied to 
the spine, the water falling from a height of at least four or 
five feet, through a tube three-quarters of an inch or one 
inch in diameter ; and its temperature should be between 
98 and ioo° Fahr. The application should be continued 
two or three minutes, and continued daily for some time. 
Dry-cupping over various parts of the spine may also be of 
service, and so also may blisters, moxas, and cauteries 
(Brown-Sequard). 

The most useful internal remedies are those which tend 



HEPATITIS. I97 

to lessen congestion — namely, belladonna and ergot of rye. 
The dose of ergot in powder may be at first three grains 
twice a day, and gradually the dose may be increased till it 
reaches six grains twice a day. Belladonna may be applied 
to the spine in the form of a plaster four inches wide and six 
or seven inches long ; and if no amelioration of the symp- 
toms follows in a few weeks, the extract of belladonna may 
be given in doses of a quarter or a third of a grain twice 
daily: and if after six or eight weeks of this treatment no 
improvement is observed, iodide of potassium, in doses of 
five or six grains Jwice a day, may be given in addition to 
the belladonna (Dr. Brown-Sequard). If meningitis is be- 
lieved to exist along with chronic myelitis, then the iodide 
of potassium should be given from the very commencement, 
along with belladonna, or with secale cornutum (Dr. Mer- 
yon). It has been given in doses of x. to xviii. grains daily 
for two months with success, in a case where loss of feeling- 
over the whole of one side was complete for two years (Bri- 
quet). Spermatorrhoea may be relieved by pressure applied 
over the region of the prostate (Thomas and Meryon). 
Electricity must not be used, even for purposes of diagnosis, 
in a recent attack. It may only be used after a long period, 
to prevent atrophy of paralyzed limbs, when the application 
of galvanic currents and the use of the flesh-brush are recom- 
mended. When oedema of the limbs exists, a warm bath to 
the part every night is of service. The bowels must be 
kept open ; and if anodynes are required, opium should be 
avoided, and hyoscyamus, conium, or Indian hemp should 
be used instead. Iodide of potassium ought to be taken 
before food in the morning, and an hour before dinner, so 
as to avoid its presumed decomposition by the gastric juice. 
The nutrition of the spinal cord ought to be improved by 
the daily use of the cold douche ; and sea-bathing may be 
of service. If symptoms of irritation do not exist, bella- 
donna is not to be given ; it is only in cases of congestion 
that it may be useful in diminishing paralysis ; and the 
same rule applies to ergot of rye. Strychnine increases the 
amount of blood in the spinal cord. It may be employed 
in paralysis only when there is no sign of irritation, and 
ought to be avoided when there are signs of congestion or 
irritation (Brown-Sequard). 

Hepatitis. — Definition. — Inflammation of the liver. 
Treatment, — Tartar emetic, in one-eighth or one-fourth 



I90 HEPATITIS. 

grain doses every two or three hours, is of service in the 
acute parenchymatous inflammation, if given sufficiently early 
— i.e. within the first three days, when there is much vascular 
excitement, a full bounding unyielding pulse, with a dry hot 
skin and scanty urine. Tincture of aconite may be similarly 
used. General blood-letting is not to be adopted. Local 
depletion by leeches over the region of the liver, and also 
round the anus, so as more directly to unload the portal 
system, must be at once resorted to in acute cases; followed 
by fomentations and large linseed meal poultices, made as 
light and soft as possible,over the hepatic region. Mustard may 
be added to them, or laudanum may be sprinkled over their 
surface. Saline purgation and alkalies, with or without col- 
chicum, are also to be freely administered. Some cases may 
be best treated by ipecacuanha, as in dysentery. In the 
early stage of acute primary hepatitis, should there be no 
diarrhoea, a mild purgative should be given at the commence- 
ment, to be followed by some mild diaphoretic, such as two 
drachms of the liquor ammonite acetatis, with five minims of 
the tincture of hyoscyamus, every half hour. After the skin 
has been thus made perspirable, the administration of chloride 
of ammonium, should be at once commenced in 20 grain 
doses twice or thrice daily, carefully noting its effects, after 
the manner advocated by Surgeon-Major Dr. William Stew- 
art {Madras Monthly Journal of Medical Science, 1872, and 
Indian Medical Gazette; Philadelphia Med. Times, April 13, 
1878). Dr. Stewart had previously (1870) published a pamph- 
let at Rangoon, in which he called the attention of the 
profession in India to the chloride of ammonium which has 
since obtained a great and well-deserved reputation in India 
and other tropical countries for the treatment of hepatic 
congestion; and it has been found of great use in this coun- 
try as well as in India (Murchison, " Clin. Lectures on Diseases 
of the Liver," 2nd Edition, 1877, pp. 136 and 624). About 
fifteen minutes after the first dose a sensation of warmth is 
experienced in the epigastrium, which gradually pervades the 
abdomen and becomes diffused over the entire cutaneous 
surface. The patient may feel "light-headed," and at times 
drowsy, and the acute pain is either removed or limited to 
some fixed point. A free and equable perspiration takes 
place over the entire surface in about a quarter of an hour, 
and with each dose similar effects will occur. Other pheno- 
mena may occur which the patient and physician must be 
prepared for — namely,symptoms referable to the liver or relat- 



HERPES. 199 

ed parts, and variously described as a " shock," or succession 
of "shocks," in the hepatic region, "as something giving 
way," a "pricking sensation," a "pulling," " clawing," 
"working" or "gnawing" sensation. Fomentations or bran 
poultices are to be applied to the seat of pain. The diet is. 
to be limited to arrow-root, sago, and barley flower made 
with milk, and barley water may be taken freely. Beef-tea 
may be added during convalescence. If liver enlargement 
continue on cessation of the physiological action of the drug, 
with feeling of stiffness, weight, or uneasiness, it may con- 
tinue to be given in smaller doses (gr. v. to x.) thrice daily. 
The patient must be kept in bed, and in the recumbent posi- 
tion. Alcoholic stimulants, fermented drinks, and solid food 
must be absolutely forbidden, and the diet restricted to the 
farinaceous food already mentioned. Hot turpentine epi- 
thems are beneficial. Iodide of potassium, in combination 
with taraxacum, is of service in the chronic forms of 
hepatitis. 

Herpes — Definition. — This lesion is expressed by red 
patches on the skin, of irregular form and variable size, upon 
each of which there arises a group, cluster, or crop of ex- 
tremely minute vesicles, for the most part in acorymbiform 
arrangement. 

Treatment. — Dry applications, such as enveloping the parts 
in cotton wool after sprinkling with oxide of zinc in fine 
powder, or with starch, I have always found better than wet 
applications. Tincture of aconite and tincture of opium 
have been applied to relieve the severe intercostal pain. 
The intolerable burning has been relieved by painting over 
the vesicated patches with collodion. It tends to preve t 
the rupture of the vesicles, and so to prevent ulceration by 
promoting healing of the parts under a scab when inflamma- 
tion has subsided. An opiate application, such as Dr. Ful- 
ler recommends in sciatica, may be of use in some cases of 
shingles, namely: — 

^ .Tinct. opii, Sp. vEther. Sulph. co. ;glycerine, aa 3 iii. ; Ext. 
Belladonna, gr. xx; misce. A strip of flannel soaked in this 
should be applied along the course of the deep-seated pain, 
and covered with oil-silk, to prevent evaporation (Waring). 

The state of the stomach and digestive organs, and diet 
generally, should be regulated. Malt liquors should be 
avoided; and, if pain is severe, opiate fomentations may be 
applied. Herpes preputialis requires no treatment beyond 



200 HOOPING COUGH. 

careful ablution with tepid water, and the interposition of a 
piece of wet lint between the prepuce and the glans penis. 
If there is much pain, the lint should be moistened with a 
watery solution of opium. 

Hooping-Cough. — Definition. — An infectious and (some- 
times epidemic) specific disease, preceded and accompanied 
by fever of variable intensity ; attended in the first instance 
by catarrh, and subsequently by paroxysmal fits of con- 
vulsive coughing, which occur in numerous, short, rapid, 
spasmodic movements of forcible expiration, suddenly fol- 
lowed by a prolonged and deep inspiration marked by a 
characteristic sound of a loud, sonorous kind, and variously 
named the "kink," "hoop," or " whoop." These paroxysms 
of expiratory and respiratory convulsive movements alter 
nately recur several times, till the fit ends by a quantity of 
mucus being brought up from the lungs, or till the contents 
of the stomach are evacuated. 

Treatment. On the invasion of the disease, beyond put- 
ting the patient on a low or very moderate diet, and attend- 
ing to the daily action of the bowels, there is little occasion 
for medicine. It will run its course ; and although no drug 
has any direct influence over this disease, one of two indica- 
tions of treatment may be followed. The fir.it is to prevent, 
if possible, cerebral irritation or convulsions, or any attack of 
inflammation, either of the lungs, the stomach, or of the 
membranes of the brain. The second indication, after the 
period of danger is past, is to prescribe such medicines as 
may diminish, mitigate, and control, as far as possible, the 
frequency of the paroxysms, co check those secretions which 
are in excess, and to excite those which are in defect. These 
objects are best obtained by mild sedatives, combined with 
gentle purgatives or laxatives. The :hoice of the sedative 
has been considered a matter of much importance. The 
Continental physicians have bestowed much praise on bella- 
donna, others on hemlock, others on henbane, while some 
have contented themselves with opium. It must be admit- 
ted, however, that none of these narcotics possess any speci- 
fic property in controlling this disease, so that the selection 
of the particular one must be left to the discretion of the 
practitioner. The mildest sedatives, such as hyoscyamus, 
or the syrup of poppies, are the safest and best. Should, 
however, belladonna be selected (as it seems to be the most 
efficient sedative), if the child be under four years of age, 
the dose ought not to exceed one-eighth or one-tenth of a 



HOOPING COUGH. 201 

grain of the extract, with the same quantity of the powder 
of the leaves in a pill, the pill being dissolved in syrup at 
the time when it is to be administered (Trousseau). The 
dose should be given in the morning ; and only once daily, 
commencing with one pill, and increasing to two or more. 
Or if hyoscyamus is chosen, half a grain to a grain every six 
or eight hours ; while, if it be the syrup of poppies, this 
medicine should be given in such fractional doses of 
a drachm as are suited to the age. Powdered belladonna root 
has been recently recommended by Vollaut. The dose is 
one-fifth of a grain, given at first once, then twice, then four 
times a day, and so on until the paroxysms begin to subside, 
when it is to be given at much longer intervals. Thus, he 
says, the spasmodic period may be positively arrested in 
three or four days (Syden. Society Year-Book, 1862). Cochi- 
neal is an anodyne which sometimes affords relief. I have 
found it of marked benefit in cases where the child has been 
losing flesh from the constant vomiting following the parox- 
ysms of cough. The tendency to vomit has always disap- 
peared under its persevering use. It is usually prescribed 
in the form of a mixture, consisting of cochineal, 10 grains ; 
subcarbonate of potash, 20 grains; sugar, ^ oz. ; water, 
4 oz.; rub together and strain (Squire's Companion to the 
Pharmacopoeia, p. 62) Of this mixture, a quarter of a tea- 
spoonful four times a day is sufficient for a child one year 
old; half a teaspoonful for a child of two years old; and a 
teaspoonful for a child of four years. Boiled apples in milk 
should be given for food. An opiate, in the early stage of 
the disease, ought not to be administered alone, as it is apt 
to check the mucous secretion. Some purgative or laxative 
ought, as a general rule in all cases, to be combined with it ; 
such as the confectio sennas, rhubarb, castor-oil or manna. 
The neutral salts, however, sit easiest on the stomach, and 
(as the medicine must be continued) they are the most agree- 
able to the patient. If at the outset or afterwards the cough 
is very suffocative, an emetic is useful. Five to nine grains 
of sulphate of copper dissolved in three ounces of distilled 
water, and a dessert-spoonful every ten minutes, is the most 
efficient (Trousseau). Nitric acid, in the following formula, 
has been found of service : — 

Acid. Nitrici diluti, f 3xii.; Tinct. Cardam. comp., 
f 3 iii,; Syrup, f 3 iiiss. ; Aquae, f 3 i.; misce. Of this mix 
ture, one or two small teaspoonfuls may be given every two 
hours (Gibb). 



202 HOOPING COUGH. 

If convulsions should come on suddenly, and without 
headache or other symptom of inflammatory action, small 
doses of any opiate, and mustard poultices to the feet, may 
relieve the patient ; and should convulsions still continue, 
an asafcetida injection may be administered. It often hap- 
pens that convulsions are combined with a suppression of 
the vomiting, and of the usual glairy discharge. In these 
cases leeches, followed by a large linseed poultice, should be 
applied to the epigastrium. If the unfavorable symptoms 
should advance, and headache or other symptoms show an 
affection of the membranes of the brain, leeches should be 
applied to the temples and cold to the head. When the 
poison excites inflammation of the tissues or substance of 
the lungs, bleeding to a limited amount by leeches may be 
required ; but the affection is not to be subdued by bleed- 
ing, as in simple inflammation. There is in severe hooping- 
cough, as in typhus, cholera, and many other affections, an 
unknown element which modifies and gives a specific char- 
acter to all intercurrent inflammations. If the intestinal 
canal be affected, some purgative, combined with calomel, 
may be necessary to free the bowels from their contents. If 
the stools be white and muciform, and the patient not re- 
lieved, an enlarged state of the follicles may be suspected, 
and a linseed poultice should cover the abdomen for some 
hours, preceded by an enema of syrup of poppies and barley- 
water, which should be administered night and morning. 

The disease having passed into the third stage, it is desira- 
ble to attempt to abridge the duration of the cough, which 
often extends to a most distressing length ; and for this pur- 
pose tonics, antispasmodics, counter-irritants, and other reme- 
dies, either externally or internally, have been recommended. 
For medicine there is, perhaps, nothing better than a few 
drops of ipecacuanha wine combined with a minute propor- 
tion of laudanum or belladonna, to be administered every 
two, three, or four hours. The more stimulant antispasmod- 
ics, as asarcetida, castor, musk, oil of amber, cantharides, and 
camphor, are the remedies which have obtained the most 
suffrages in the cure of this stage of hooping-cough. The 
two first are in most esteem. Asafcetida should be given in 
emulsion, in the dose of one or two grains to a child two 
years old, repeated three or four times a day, or even as often 
as every two or three hours. Cullen preferred cinchona to 
asafcetida, and considered it " the most certain means of 
curing the disease." Many other remedies have been men- 



HYDROCEPHALUS, ACUTE AND CHRONIC. 203 

tioned, as alum, hydrocyanic acid, oxide of zinc, arsenic, 
and many preparations of iron. All of these remedies have 
been found to a certain extent useful as tonics ; but in esti- 
mating the results of remedies, we should be careful not to 
mistake temporary recovery for cure ; and the fact of so very 
many remedies being highly spoken of suggests doubt as to 
the value of either. 

When internal remedies have failed to make any impres- 
sion, relief may be obtained by means of local treatment, or 
by derivatives, as by some liniment or embrocation, as the 
liniment of camphor or of ammonia, or with ascfcetida, oil of 
amber, oil of turpentine, or the tincture of cantharides. The 
general opinion, however, is, that these do little good unless 
they contain some opiate, whose absorption they facilitate, 
and this may be attended with danger. The application of 
strong solution of nitrate of silver to the skin over the larynx 
has been much recommended. Foot baths and the warm 
bath have also been used, and often with much efficacy. A 
change of air is a resource of great value. A change from 
the bad air of a town to the purer air of the country is at all 
times a great benefit ; it has also been found that a change 
from the country to the town is not less beneficial, and that 
the patient is benefitted even by the removal to a short dis- 
tance from home. 

Dietetic and General Treatment. — The patient should not 
be allowed animal food from the commencement almost to 
the termination of the disease in its acute form. It is desira- 
ble also that the temperature of his apartment should be 
regulated, and that he should not be exposed to any consid- 
erable or sudden change from heat to cold. In mild weath- 
er also, if no local symptom forbids, he should be permittei 
to take exercise in the open air. He should likewise, nex. 
his skin, wear flannel. 

There are no known means of prevention, except an entire 
removal from every source of contagion. 

Hydrocephalus^ Acute— see Meningitis, Tubercular. 

Hydrocephalus, Chronic. — Definition. — Effusion of 
fluid in the subarachnoid space, or generally distending the 
ventricles of the brain, and differing from cerebrospinal 
fluid in containing more albumen (Hoppe) ; occurring chiefly 
among children, and when discovered later in life, generally 
dating back to childhood. The tissue of the brain in con- 
tact with the fluid, especially the commissural parts, is apt to 



204 HYDROPERICARDIUM HYDROPHOBIA. 

be broken down by oedema into a thin white pulp (hydro- 
cephalic or white softening). 

In hydrorachis the effusion of fluid is within the cavity of 
the spinal cord. 

Treatment. — For chronic cases of hydrocephalus there can 
be no relief. In cases of hydrorachis, where a tumor is as- 
sociated with spina bifida, iodine injections have been pro- 
posed (Velpeau, Debout, Brainard, Gross, Meryon). In op- 
erating, the puncture should be very small, by a small flat 
curved needle, directed subcutaneously into the sac. A 
drain of the fluid may then be allowed to escape through a 
canula, and the injection used must be very weak at first, the 
object being to excite a slow process of inflammation in the 
cyst. One-eighth of a grain of iodine, and a quarter of a 
grain of the iodide of potassium in solution, is the quantity 
prescribed for injection by Dr. Gross. Dr. Brainard uses a 
solution composed of five eighths of a grain of iodine and 
half a grain of iodide of potassium to one drachm of water. 
The puncture is to be closed with a twisted suture, and coat- 
ed over with collodion. An anodyne should be administered 
and the child kept lying on its face. Mr. W. M. Coates, of 
Salisbury, has been also successful by a similar method of 
treatment. If the life of the child be saved, paraplegia is 
still apt to remain, and perhaps involuntary defecation and 
micturition (Meryon in Brit. Med. Journal, July n, 1863, 
p. 28 • also " Practical and Pathological Researches on the 
Various Forms of Paralysis," p. 25). 

Hydropericardilim. — Definition. — An increase of the 
normal liquor pericardii, containing little albumen, and anal- 
ogus to the fluid of chronic hydrocephalus. 

Treatment must be regarded by the attendant circumstan- 
ces of the case, and in accordance with what has been already 
written on the subjects of pericarditis and dropsy. Paracen- 
tesis may be required. 

Hydrophobia. — Definition. — A disease peculiar to ani- 
mals of the canine or feline race, the specific poison of which 
being implanted by them in man, or in other animals, pro 
duces a similar malady. The saliva or secretion issuing from 
the mouth of the diseased or rabid animal contains and so 
conveys the poison whicn inoculates rabies, cither through a 
wound or through a thin epidermis with abrasion. The period 
of incubation of the poison after inoculation varies from tour 
to sixteen weeks, or even longer, before the malady becomes 



HYDROPHOBIA. 205 

developed. The disease is characterized by severe constric- 
tion about the throat, spasmodic action of the diaphragm, 
and distress at the epigastrium : all of which are aggravated 
or brought about by attempts to take fluid, or by the least 
breath or current of air on the surface of the body, which 
produces, in the first instance, an effect resembling that pro- 
duced upon stepping into a cold bath. Saliva, tenacious and 
clammy, issues from the mouth. Paroxysms of phrensy, or 
of uncontrollable impulsive violence (rabidity), supervene. 
The duration of the disease varies from three to six or seven 
days, the greater number of cases terminating in death on the 
second and fourth days from the accession of symptoms. 
Death is generally sudden, and unexpected at the moment. 

Treatment. — As there are but few authenticated cases of 
recovery from hydrophobia, so there are few instances of any 
mitigation of the symptoms by the use of medicine. All that 
remains is to mention the most leading experiments that have 
been made, with the hope that, as they have not been suc- 
cessful, they may not be wantonly repeated. 

Dr. Hamilton gives twenty-one cases, and adds, " many 
hundreds more are on record," in which venesection has 
been unsuccessful, though frequent and copious. Opium has 
been given by Dr. Babington, to the enormous amount of 180 
grains of solid opium in eleven hours, without the slightest 
narcotic effect, or the slightest mitigation of the symptoms. 
Nord has given a drachm of belladonna in twelve hours, 
without any benefit. Dr. Atterly gives to a chile? eight years 
old two drachms of calomel by the mouth, and rubbed in two 
ounces and a half of strong mercurial ointment in a few hours, 
with an equal want of success. A case, however, is related 
by Ligget, which is said to have been successfully treated by 
half-drachm doses of calomel, given to the extent of ptyalism, 
induced in three days, after four and a half drachms of 
calomel had been taken. The case really appears to be one 
ot hydrophobia ; and recovery is said to have been complete 
by the twelfth day (Amcr. Quar. Journal of Medical Science, 
Jan., i860). Iron, arsenic, nitrate of silver, camphor, musk, 
cantharides, turpentine, tobacco, acetate of lead, ammomacal 
solutions of copper, hydrocyanic acid, galvanism, strychnine, 
nitrous oxide, chlorine, and guaiacum, have all been given in 
equally large doses, but have signally failed. In addition to 
these, Ploucquet in his " Literatura Medica Digesta," has enu- 
merated nearly 150 other medicinal remedies. The failure 
of every remedy by the mouth, and the inefficacy of opium, 



206 HYDROPHOBIA. 

of morphine, and of laurel water, even when injected into the 
veins, so convinced Majendie that in hydrophobia the con- 
stitution was armed against the action of any medicinal sub- 
stance, that on a patient laboring under this disease being 
brought to the Hotel Dieu, he determined to rely for all treat- 
ment on an injection of warm water into the veins. The 
patient, at the time of the operation, is represented as being 
absolutely insane, so as to require to be restrained. In this 
state, and with a pulse of 150, Majendie injected into his 
veins, in the course of two hours and a quarter, two pints of 
water, at the temperature of ioo°. At the conclusion of this 
operation the pulse had fallen to 80, and the patient had re- 
covered his senses, so that restraint was -no longer necessary. 
The sequel, however, renders it doubtful whether this miti- 
gation was desirable at the price of the intense suffering which 
followed. The poor man lived eight days afterwards, but the 
despondency and mental agitation quickly returned, and at 
the end of three days the poison (or the state of the blood 
induced by it and the* warm water) appeared to setup a new 
series of actions on the synovial membranes of the wrists, 
elbows, and knees, attended with excessive pain, so that ne 
was unable to bear the weight of the bed-clothes, and he died 
in great torture. The articulations thus affected were found, 
on post-mortem examination, to be greatly inflamed, and 
their cavities filled with pus. This case is remarkable as 
being the one in which life was prolonged for the greatest 
period of time recorded of this disease. The experiment lias 
since been repeated by Gaspard and others ; but the mitiga- 
tion, if any, has been so slight and transient as to give no en- 
couragement for repeating it ; and, tried on the rabid dog by 
Youatt and Mayo, it proved eminently unsuccessful. 

The property which some animal poisons have of controlling 
and of interrupting the actions of other morbid poisons on 
the constitution has caused even animal poisons to be tried 
in the cure of this disease. The rapid and powerfully acting 
poison of the viper led to the hope that the bite of that rep- 
tile might prove an antidote to the hydrophobic virus ; but 
the experiment, tried in France, Germany and Italy, upon 
animals, has been entirely unsuccessful. M. Grindard con- 
ceived that the vaccine virus might influence hydrophobia, 
and he vaccinated a hydrophobic child in three places, and 
afterwards injected five charges of vaccine lymph into the 
veins ; but the child died without any marked remission, and 
in the usual time. The following draught has been found 



HYSTERIA. 207 

rather to promote euthanasia than to hold out any prospect of 
cure : — 

^ Spirit. iEther. Sulph., Tinct. Opii, aa mxx ; Spirit. 
Amnion. Aromat., 3 ss. ; Chloroform, mxx ; Mist. Camph., 
5 iss. ; misce. To be given as often as may be considered 
safe (Cunningham, Carden). 

On the same principle chlorodyne may too be given. The 
vapor bath is sometimes useful in moderating spasm. 
Having regard to the symptoms generally, and to the morbid 
appearances as being in many respects similar to tetanus, the 
remedies recommended in that disease might be successful in 
some cases of hydrophobia. Sialagogues have recently been 
advocated upon theoretical considerations, especially the ex- 
tractum jaborandi fluidum, of which one drachm represents 
one drachm of the leaves as prepared by Messrs. Gall & Co. 
Curare has also been employed, but not with success, mainly 
at the suggestion of the late Dr. Francis Gibson of St. Mary's 
Hospital, London. For this purpose, Messrs. Gall & Co. 
have prepared an injectio curare (three minims being equal 
to one-third of a grain), which it is advised should be injected 
at intervals of a quarter of an hour or more, as soon as indi- 
cations of the physiological action begin to diminish. 

Preventive Treatment. — The probabilities are, that unless 
the operation of excision, or cauterization, be performed 
within a few minutes after the bite of the rabid animal, it is 
impossible to save the patient from the fatal disease, which, 
according to the susceptibility of his constitution, may 
tnreaten him at any moment. In all probability no prophy- 
lactic medicine exists in nature, and the administration of 
any potent substance by way of prevention is worse than use- 
less ; for, without protecting the patient, it may injure his 
constitution. Mild remedies, if they tend to tranquilize his 
mind and appease his apprehensions, may be innocently em- 
ployed. 

The theory which maintains that a zymotic incubation first 
takes place in the wound, by which the poison is originally 
implanted, suggests the most rational prophylactic — namely, 
to destroy entirely by potass fusa the whole cicatrix, where 
practicable ; or, by some other surgical means, entirely to 
remove it at as early a period as possible, and previous to the 
occurrence of symptoms. 

Hysteria. — Definition: — A complex disorder of all the 
cerebral functions, of a chronic kind, occurring mainly in 
females from the age of puberty upwards. It is probably 



2o8 HYSTERIA. 

associated with some morbid state of the emotional or 
sensori-motOr centres, and presents every variety of altera- 
tion, so that the phenomena of hysteria are protean, simulat- 
ing or mimicking the phenomena of almost every other dis- 
ease, while the most common and characteristic features of 
the affection are certain motorial changes of a convulsive 
nature, usually of paroxysmal occurrence. 

Treatment. — The treatment may be divided into what 
should be done during the fit, and into what should be done 
afterwards. 

When the patient falls into a fit of hysteria, the first thing 
to be done is to loosen everything tight about her person. 
The window should be opened, and the cold air allowed to 
blow over her. She should then be laid in the horizontal 
posture on a bed, or on the floor, as a means of rendering 
the circulation through the brain more equal, and to enable 
us the more readily to control the convulsive movements of 
her body. This being done, many modes of further pro- 
ceeding may be followed. Some recommend, in plethoric 
cases, that the patient should be bled — a remedy certainly 
in many instances manifestly improper, and in all of doubt- 
ful efficacy. When the jaw is locked, an enema, consisting 
of the yolk of an egg beat up with two drachms of asafcetida, 
with half a pint of water added, may be administered; or, 
still better, an enema of turpentine, in which half an ounce 
of turpentine is similarly mixed with the yolk of an egg, and 
half a pint of water added. These remedies, in some in- 
stances, instantly remove the affection, but in other cases 
not for some hours. Another remedy is to fill the mouth 
with salt. The remedy, however, which supersedes all 
others, and is unquestionably the best, is a good drenching 
with cold water. 'I believe there is more virtue in cold 
water than in any other single remedy " (Watson). If the 
patient lie on the bed, the head should be drawn over its 
side, and a large quantity of water poured on it from a con- 
siderable height out of a pail, jug, or other large vessel, and 
directly over the mouth and nose of the patient, so as to 
stop her breathing, and compel her to open her mouth. 
This practice is generally introduced into hospitals; and un- 
til it was adopted it was not unusual to see three or four 
patients in hysteria in the same ward, and at the same time. 
Under this practice, however, an hysterical case is rare, the 
fit seldom occurs twice in the some person, and the affection 
never becomes epidemic. 



HYSTERO-EPILEPSY ICHTHYOSIS. 209 

After the paroxysm is over, if the patient complains of 
continued headache, a few leeches to the temples may be 
necessary, especially if the urine be small in quantity and 
high colored ; but in all other cases leeches, blistering, or 
cupping should be avoided, as tending rather to aggravate 
than to control the disease. The next object is to regulate the 
bowels by such remedies as may be necessary, and at the 
same time to support and tranquillize the patient by stimu- 
lants, such as ether or asafcetida, combined with hyoscyamus 
in the form of tincture, the syrup of poppies, or small doses 
of morphia. 

Niemeyer recommends the chloride of sodium and gold as 
a restorative nerve tonic. He prescribes in the form of a 
pill, as follows : 

]J. Auri. chlorat. natronat, gr. v.; Gum. tragac. Co., 3 i.; 
Sacc. Alb., q. s. ; misce. Divide into forty pills, of which one 
is to be taken an hour after dinner, and another an hour after 
supper. After a time, two are to be taken as a dose at one 
time, and increased gradually till eight pills a day are taken; 
a cold shower bath twice daily. 

The state of the uterine functions must always be inquired 
into. If leucorrhcea be present, or the menstruation be pro- 
fuse, the mineral acids, or the bitartrate of potass., will be 
found most efficacious, by restoring a more healthy state of 
.the deranged organs. 

The urine is often suppressed for a time after an attack of 
hysteria ; but unless the bladder be sensibly, and perhaps 
painfully distended, no attempt should made to draw the 
urine off. Something more should be hazarded to avoid 
this necessity, for the catheter once passed, that operation 
will require to be performed morning and night, perhaps for 
several months. It is important that pity, attention, and 
sympathy be withheld as much as possible from hysterical 
patients. The moral and bodily condition deterioates under 
such influences. Firmness is essential for successful treat- 
ment. 

Hystero-Epilepsy — See Epilepsy. 

Icterus — See Jaundice. 

Ichthyosis. — Definition. — A lesion which involves the 
whole tissue of the skin and is characterized by the growth 
of thick, dry, imbricated scales o* a dirty grey color, resting 
upon a perfectly uninflamed surface, and never accompanied 
by pain, heat, or itching. 
J4 



2IO ILEUS INFLUENZA. 

Treatment. — Remedial measures are only, palliative, con- 
sisting mainly of mucilaginous and glycerine lotions, with 
vapor baths to mollify the roughness. Potash solutions, or 
other preparations of potash, are contra-indicated as local 
applications. 

Ileus — See Intestines, Obstrurtion of. 

Infantile Convulsions — See Convulsions, Infantile. 

Influenza — Defi?iition. — A specific catarrhal inflamma- 
tion of the mucous membrane of the air passages, and gen- 
erally also of the digestive organs, with severe constitutional 
disturbance. The disease is invariable in its essential char- 
acteristics, frequently prevailing as an epidemic, attended 
with lassitude and prostration to an extreme degree, with 
special and early implication of the naso-laryngo-bronchial 
mucous membrane. Frequent chills occur, and great sensi- 
bility to cold exists over the surface of the skin; the eyes 
become injected, and tend to fill with tears, the nostrils dis- 
charging an acrid fluid; attended with fixed and intense 
pain in the head, mostly frontal over the eyes, sometimes al- 
so attended with giddiness. The nights are sleepless, with 
delirium or lethargy; cough prevails with yellow expectora- 
tion, most troublesome at night, and tending greatly to in- 
crease the headache. Fever attends the disorder, some- 
times slight and sometimes severe, and of a type varying in 
different epidemics and localities. The duration of the fever 
is definite, of from four to eight days (Parkes). The sense 
of taste is greatly disordered, and t here is great anxiety 
and depression over the region of the heart. 

Treatment. — As a general rule, the great majority of cases 
in epidemics of influenza have scarcely required any medical 
treatment. In 1782 it was observed that "many, indeed, 
were so slightly indisposed as to require little or no medi- 
cine; nothing more was wanted to their cure than to abstain 
for two or three days from animal food and fermented 
liquors, and to use some soft, diluted, tepid drink. A gentle 
purgative at the beginning of the disease was useful in mod- 
erating the fever; and nature seemed to point out the repe- 
tition of it afterwards when there was pain in the stomach 
and bowels, and a tendency to diarrhoea." The same was 
observed in 1762. Nothing, likewise, was observed so suc- 
cessful in mitigating the cough as to open the bowels, and 
afterwards giving a gentle opiate at night. In the year 1837 
it was also remarked that, as long as the symptoms werelini* 



INFLUENZA. 211 

ited to cough, hoarseness, headache, or other pains moderate 
in degree, the patients all recovered by putting them on a 
low diet, by attending to their bowels, and confining them 
for a few days to the house. It was quickly found that the 
disease ran a course scarcely influenced by medicine. A 
small number, however, required medical aid, either from 
the severity of bronchitis, the occurrence of pneumonia, of 
angina, or of severe dyspnoea, of the disordered state of the 
bowels, or more frequently from the debility induced by the 
disorder. Blood-letting, even by leeches, is always hurtful. 
It does not relieve the fever, and increases the nervous de- 
pression. But when pleurisy, bronchitis, or pneumonia may 
supervene, leeches to the chest, or cupping, may relieve 
symptoms. A mild purgative dose of calomel (one to three 
grains) should be given once at first, followed by a saline 
purgative. Dark-colored motions are brought away, the 
spirits improve, and the fever abates. But mercury must not 
be given beyond an occasional purge. Emetics are also to 
be avoided. They increase depression, and are apt to pro- 
duce irritability of the stomach difficult to subdue. Hot 
fomentations, bran, mustard, or linseed meal poultices to the 
chest, or flannel or cotton wool envelopes, are often of great 
comfort and usefulness. During convalescence sulphate of 
zinc is a useful tonic when the expectoration is thin and spu- 
mous; and alkalies are more useful when it is viscid and 
glairy (Peacock). Nitrate of potash, highly diluted and 
mixed with lemon juice and sugar, is a most useful drink. 
From 60 to 120 grains in twenty- four hours may be taken. 
Stimulants are early called for on account of the intense 
prostration. Opium must be used with great caution in the 
severe pulmonary complications. Its use ought to be put off 
till the later stages, otherwise it may increase the tightness 
of the chest and the dyspnoea. It must not be given till all 
danger of lung congestion is past. When the fever and other 
immediately alarming symptoms of the influenza had ceased, 
there frequently remained a teasing cough, and the conva- 
lescents in general complained of languor, want of appetite, 
and that their sleep was broken and unrefreshing. For re- 
moving these complaints, change of air and riding on horse- 
back were most effectual. To some they were absolutely 
necessary; and, in addition to these, mild tonics, or the nat- 
ural chalybeate waters .drank at the Spas, were of singular 
service. In slight cases it was sufficient to limit the patient 
to white fish and puddings; and in the more severe forms, to 



212 INSANITY. 

slops and light puddings. The night air was universally pre- 
judicial. It does not appear that any precautionary treat- 
ment was of service in preventing the spread of the disease 
among the attendants on the sick. 

Insanity. — Definition. — Disorders of the mind consequent 
on brain lesions, or attendant on affections in which the 
brain is secondarily or remotely implicated. Feelings, Emo- 
tions, Intelligence, or Will of the patients, conjointly or sep- 
arately, are exalted, perverted, or impaired. 

The Treatment of insanity resolves itself into the medical 
and the moral management of the case. Medicine indirectly 
acts upon the brain as it does upon other organs, so as favor- 
ably to influence the course of the disease. It regulates the 
different actions and secretions of the viscera of the body, 
and thus improves the general health, so that the happiest 
results are obtained by the early and judicious use of medi- 
cinal agents. No uniform method of treatment can be taught. 
The condition is essentially one of asthenia, feebleness, 
anaemia, or exhaustion. Local bleeding may be adopted in 
some cases with reference to a distant viscus. Leeches to 
the vulva and thighs are beneficial in some cases of mania, 
monomania, or melancholia, in adults, when such disorders 
of intellect are concurrent with the menstrual period ; and 
to the sphincter ani in those cases obviously connected with 
suppressed haemorrhoids or hepatic congestion. In some in- 
stances leeches may be applied with benefit to the Schneide- 
rian membrane, particularly in those cases occurring in early 
life, and in persons of plethoric constitution and of sanguine 
temperament. Illusions of hearing or of vision, which had 
embittered the patient's life, have been removed by leeching 
behind the ears or over the superciliary ridges. The utility, 
in acute mania, of prolonged hot baths was much insisted 
upon by the late Dr. Winslow. The patients remain from 
eight to fifteen hours in them, at 82 ° to 86° Fahr., whilst 
a current of water at 6o° is continually poured over the head. 
Various details of what is now known as hydropathic treat- 
ment have recently been introduced, with great advantage, 
into English asylums, such as the Russian or vapor bath, the 
wet sheet, wet pack, and the like. Packing in the wet sheet, 
warm baths with cold to the head, will often procure sleep 
more certainly than medicine of the sedative or hypnotic class. 

Sedatives, or agents which modify directly the condition of 
the cerebral tissue, and which procure sleep or rest to the 
brain, constitute very valuable remedies. In recent acute 



INSANITY 513 

Cases they are generally admissible, and are only contra-in- 
dicated if constipation keeps up the excitement and sleep- 
lessness* or if local cerebral irritation exists; or if the gen- 
eral health and secretions are disordered. In the various 
chronic forms of melancholia they are most useful, and in 
suicidal insanity. The meconate and hydrochlorate of mor- 
phia should be uninterruptedly and perseveringly given, in 
gradually increasing doses, until the nervous system is com- 
pletely under their influence. The preparation Dr. Millar 
has found most useful and the least productive of constitu- 
tional disturbance, is a solution of opium in water, acidu- 
lated with citric acid (containing about one-sixth of crude 
opium) administered every four or six hours, in doses of 
from 10 to 20 minims, (equal to 10 grains of crude opium 
daily), and continued until the patient feels he can sleep 
without it. So also will chlorodyne and chloro-morphine be 
of use in some cases, as well as chloral, bromide of potas- 
sium, and hyoscyamus. Indian hemp is an extremely useful 
sedative, not hitherto appreciated sufficiently for many rea- 
sons. (See an excellent paper on its uses by Professor Rus- 
sell Reynolds, in Beale's Archives, Vol. II., p. 154-) It re 
lieves pain, is soporific, anodyne, antispasmodic; and while 
conducing to sleep, promotes at the same time diaphoresis 
and diuresis, without producing headache, vertigo, constipa- 
tion, or impairing the appetite. The dose varies from one- 
sixth to one-half grain for a child, and from one-third to one 
grain and a half for an adult. In cases of mental or emo- 
tional disturbance it will be found extremely useful, espe- 
cially where there is deranged cerebral circulation, with pain 
and delirium; in cases of incipient insanity after fever or 
sunstroke; and in cases of senile ramollissement. Recently 
digitalis, conium, belladonna, have been extensively em- 
ployed as calmatives. Endermic medication in insanity offers 
numerous advantages; and hypodermic injections, especially 
of calmatives and soporifics, have also recently been em- 
ployed- Dr. Reissner's experience leads him to recommend 
morphia, codeia, and narceia, the former being much the 
most useful, and the others only to be used in special cases 
when morphia fails. Narceia he recommends in those cases 
where the injection of the morphia produces unpleasant 
symptoms of an uncomfortable kind — not to say of a pois- 
onous tendency. Narceia he considers a special remedy in 
such cases. Preparations of opium introduced into the sys- 
tem by the hypodermic method, are more speedily mani- 



214 INSANITY. 

fested by the results than when administered by any other 
mode.. The acetate of morphia is the best form with a min- 
imum of acetic acid, in hot distilled water, in the proportion 
of five grains of acetate of morphia to one fluid drachm of 
water or of glycerine. One minim of this represents -^ of a 
grain — a safe and useful minimum dose. Two minims (equal 
to -J- of a grain), is the best commencing dose for relief of 
severe pain, and as a hynoptic in states of nervous irrita- 
bility, whether connected with disorder of the intellect or 
other diseases. Three minims or % of a grain, is an unsafe 
dose to commence with; dangerous and even fatal results 
have resulted from such a dose. It should not be given till 
smaller doses have been tried. Used endermically, the salts 
of opium are reckoned to be three times as powerful as when 
swallowed (Waring). Hydrate of chloral is of use in subdu- 
ing the delirium of mania and sometimes in obtaining sleep, 
combined or not with bromide of potassium. 

Purgatives may be regularly required. When the bowels 
are constipated the form is best determined by the state of 
the tongue, and sometimes by the idiosyncrasies or proclivi- 
ties of the patient in regard to medicine taking. Supposing 
the tongue to be white and coated, the sulphate of magnesia, 
or other neutral salt, combined with tincture of hyoscyamus, 
in the proportion of 3 j- of the former to mxv. to mxxx. of 
the latter, in camphor mixture, is a formula to be recom- 
mended ; so also is calomel (five grains) with compound ja- 
lap powder ( 3 i-), and a little powdered ginger ; and also 
watery extract of aloes nightly. If, on the contrary, the 
tongue be clean, the cathartic should be given with some 
slight bitter, as the infusion of orange peel or of gentian. In 
some cases the bowels are not only exceedingly obstinate, 
but the patient may be greatly averse to all medicines. In 
such cases one or two drops of croton oil placed on the' 
tongue or introduced in food produces free evacuations. 
Mild purgative treatment formed the basis of cure in the 
school of Pinel and of Esquirol, usually combined, in cases 
of violence, with the application of cold to the head, and of 
warmth to the lower parts of the body ; such as placing the 
patient in the warm bath, and giving him the cold douche — 
a remedy since more particularly insisted upon. Tho fur- 
ther treatment consists in restoring any other functions that 
may be in defect or in excess, as the functions of the uterus 
in the female, and of the liver or heart in both sexes, by the 
usual remedies applicable for these purposes. 



INSANITY. 215 

When there is anaemia, vegetable tonics, combined with 
the preparations of iron, are of great service. At the same 
time the patient ought to be supplied with an abundance of 
nutritious and easily digested food. It quiets the noisy, and 
lessens the dirty, mischievous, and destructive propensities 
of others. Where there is an absolute refusal of solid food, 
as in acute mania, it is essential that the liquids (which the 
patient for the most part readily takes) should contain as 
much nutritive material as possible. Strong soup and broth, 
beef-tea mixed with milk and with arrow-root, must be given 
often. The best form of food is that in which eggs and 
milk largely enter. Two or three eggs beaten up, and mixed 
with a half a pint of warm milk, warm ale, or warm porter, 
may be given with a sedative every four to six, or eight 
hours, and continued daily till excitement abates, or the abil- 
ity to take solid food returns. Such stimulant food is well 
borne, and absolutely necessary in cases of acute mania. In 
melancholia, three to twelve ounces of wine may be neces- 
sary in the twenty-four hours ; and there is also a tolerance 
of opium. Ten minim doses maybe given three times a day. 
If impulsive tendencies are manifest with despondency, bro- 
mide of potassium should be given in thirty to forty grain 
doses, with an iron mixture. If the tendency is to atonic 
lethargy, large doses of quinine, or small doses of strychnia, 
are to be given with the iron. Easton's syrup is valuable. 
In neuroses of the stomach and gastralgia, arsenic and bis- 
muth are both of much service in small doses. Muriate of 
ammonia is of special use in those cases in which the de- 
pression is intense and paroxysmal in character. 

The moral management of disorders of the intellect is by 
many supposed to constitute the more efficient mode of cure; 
and it must be admitted to be a most important adjunct. 
The first important rule is to remove the patient at once from 
his family. In slight cases this step is necessary in order that 
he may be induced to exercise such command over himself 
as he possesses, and to remove him from influences which 
may have been aggravating his morbid state ; such as finding 
himself a prisoner, instead of being master in his own house. 
In severe cases it is necessary, in order to prevent his doing 
mischief either to himself or others. In melancholia no form 
of treatment is so efficacious. The great object is to break 
up the monopoly of grief and fear which has obtained pos- 
session of the mind ; and if a new interest can be awakened 
or a fresh hope insinuated, this object is in a great part ob- 



2l6 INSANITY. 

tained. At the same time solitary brooding and idleness 
must not be permitted; and at least cheerful companionship 
must be secured. It is important also to seek out and to 
treat visceral or constitutional diseases and relieve them — 
e. g., gout, syphilis, uterine disorders, climacteric conditions, 
and the like. The main feature in the moral management 
of the insane in this country is the abolition and absence of 
mechanical coercion or restraint. The beneficial action of 
this system, generally known as "the non-restraint system," 
is now thoroughly recognized in England and Scotland, 
where it has been gradually established in every asylum since 
1847-48. But there are certain exceptional phases of insan- 
ity, in which some mechanical restraint is the most humane 
mode of treatment — the only mode, indeed, of avoiding cer- 
tain catastrophes of too common occurrence. In certain 
conditions of excitement it is proper to place the patients at 
once in a darkened room, remote from the noise and the 
means of injury to himself or others, so that as few objects 
as possible may irritate him, just as a patient. with his eyes 
affected is kept in a darkened room. The effect of such se- 
clusion is generally of a soothing character; and in not a 
few cases of periodic mania it is eagerly sought for by the 
patients themselves. When a case of melancholia is of se- 
vere type from the first, muriate of ammonia and tincture of 
opium are the most valuable egents. There is a tolerance of 
opium in simple melancholia. So long as depression lasts 
it is taken with benefit to every function. When depression 
terminates it may be abandoned at once without inconveni- 
ence. As convalescence advances the patient should be in- 
duced to undertake some manual labor, or some office in 
the asylum or household, which, by amusing his mind, will 
invigorate his body, and greatly tend to restore the healthy 
working of his brain. There are no more powerful moral 
medicines than "occupation," "recreation," and "educa- 
tion." Occupation should be such that no time is left for 
idleness; or for sitting brooding over morbid fancies. The 
curative results of well-chosen means of recreation cannot 
be over-estimated. When the circumstances of the patient 
admit of it, traveling, which embraces change of air and 
change of scene as well as exercise, is oftea highly salutary 
in incipient cases; and much has of late been done by the 
judicious introduction of music and other amusements into 
asylums. Change of scene acts often like a tonic to the de- 
pressed and jaded powers; but where there is great restless- 



INSOLATION INTERMITTENT FEVER. 217 

ness and feverish perturbation, traveling and change of scene 
should not be resorted to (Dr. J. Crichton Browne). Con- 
certs, balls, conversaziones, evening entertainments, pic-nics, 
excursions, fetes champetres, athletic games, pedestrian ex- 
cursions, public amusements in towns, and carriage drives, 
are all legitimate and well-approved means of maintaining a 
constant and varied succession of recreation adapted for all 
classes of the insane. When reason is restored and the af- 
fections again fix themselves on their natural objects, and 
when the emotions are under control, the patient may be al- 
lowed to see his friends, and have his attention directed to 
the affairs and interests of his family ; but it should be re- 
membered that the mind remains weak and enfeebled for 
some time after apparent recovery ; and, consequently, the 
patient's restoration to society should be gradual. 

An hospital for the insane, or a lunatic asylum, is the 
most fit and proper place for a "person of unsound mind." 
But every such asylum ought to be governed by one superin- 
tendent, who should be a medical man — an officer of health 
to the community over which he presides. He ought to have 
the means of controlling all sanitary arrangements in whole 
and in detail — of avoiding over-crowding — of preventing and 
destroying effluvia — and of examining the quality of the food, 
the water, and the drugs furnished to the establishment. 
Chemical and pathological appliances ought therefore to be 
at his disposal for his use. The number of patients who 
may be thus under the supervision of one medical head in 
an asylum ought not to exceed 200 (Esquirol, American 
Commissioners in Lunacy). Premature removal from asy- 
lum treatment, in opposition to medical advice, is greatly to 
be deprecated ; and its baneful results are frequently to be 
seen, especially in the sad endings 01 cases of suicidal mel- 
ancholia. In such cases an acknowledgment should be re- 
quired oi the recipient oi the patient, or his friends, that he 
is removed notwithstanding the assurance given by the med- 
ical superintendent that the patient is not recovered, and is 
unfit for removal (Dr. Lindsay, Thirty-second report, p. 14). 
Such removals not unfrequently induce a change of type 
from acute and curable to chronic and incurable mental dis- 
ease. 

Insolation — See Sumtroke. 
Intermittent Fever — See Ague. 



218 INTESTINES. HEMORRHAGE FROM. 

Intestines, Hemorrhage From — Definition. — Loss of 

blood from some portion of the mucous membrane of the 
alimentary canal below the stomach. It may have its seat 
in the small intestines, or in the large, or in both, but prob- 
ably never flows from the whole length of the canal. 

Treatment. — Ergot is a useful remedy. Dr. Macgre- 
gor, of Glasgow, records a case of persistent periodical 
haemorrhage from the bowels which yielded to ergot when 
all other remedies had failed (G/as. Med. Journal, June, 
1867). In haemorrhage from the bowels in enteric fever, 
the tincture of the perchloride of iron is often useful, and 
if associated with much arterial action, it may be com- 
bined with digitalis, as in the following formula : 

5 Tinct. Ferri Perchlorid., m xxx. ; Tinct. Digitalis, m 
xv. ; Aq. Menth. Pip., 5 iss., repeated every four hours 
(Waring). 

In the event of failure, the iron tincture may be used as an 
enema, combined with opium, in the following formula 

5* Liq. Ferri Perchloridi, m xv. ; Morphiae 'iydrochlor. 
gr. y 2 ; Aq. Tepid, 3 iv. ; Misce (Dr. John Harley). 

In cases where there is a tendency to syncope from intes- 
tinal hemorrhage, oil of turpentine (m x. to m xv.) every half 
hour or hour has proved an effectual remedy (Dr. John Har- 
ley). The treatment of haemorrhoids consists — (1.) In fo- 
menting them with hot water, with the free use of Castile 
soap, when they are in the acute stage of inflammation, and 
of a dark red appearance, throbbing, and painfully burning, 
as if a red-hot coal had been applied to them. In this condi- 
tion dusting with calomel has been found to give relief (Bid- 
die, Atkinson, Practitioner, Vol XXIII,; 1879, p. 104). (2) 
If the pains continue excessive, a lew leeches maybe applied 
to the margin of the anus ; and, at the same time, the bitar- 
trate of potash, combined with sulphur and guaiacum, in the 
proportion of one part sulphur and of guaiacum to two of 
cream of tartar, a teaspoonful being taken three or four times 
a day, which ought to keep the bowels gently relaxed. Nu- 
merous cases have now been published which conflrm the 
value of glycerine, in doses of a dessert-spoonful twice a day, 
in the treatment of internal and external haemorrhoids (Dr, 
David Young, Practitioner, 1. c, p. 251). The protruded 
bowel ought also to be carefully washed with a sponge and 
cold water after defecation, and the use of paper entirely 
discarded. To relieve the weight and tension after use of 
soap and fomentation, compound gall ointment and bella- 



INTESTINES, INFLAMMATION OF OBSTRUCTION OF. 219 

donna extract, in equal parts, should be freely applied every 
three or four hours till the pain subsides. In the chronic 
stage, the common pitch ointment is the best application (F. 
P. Atkinson, 1. c.) Stringent rules ought to be laid down as to 
diet, which should be light, and the patient limited to 
French and Rhenish wines. Ablution with cold water 
should be practiced morning and evening ; and some per- 
sons are sufficiently sthenic even to bear with advantage 
an injection of cold water after each evacuation of the 
bowel. In prolapsus ani and haemorrhoids, Professor Cle- 
land recommends the use of liquor bismuthi as an enema. 
A dessert-spoonful of the liquor is to be mixed with half 
a wine-glassful of fluid starch, and, after getting into bed 
and returning the bowel to its place, to introduce this enema 
and retain it. 

Intestines, Inflammation of— See Enteritis. 

Intestines, Obstruction {&— Definition. — An obstacle 
or impediment which obstructs the passage of contents 
through the bowel. 

Treatme?it. — In all cases of intussception, whether oc- 
curring in children or adults, the administration of purga- 
tive medicines tends to aggravate the lesion and the symp- 
toms. Accordingly the rule of practice is absolute — 
namely, " to withhold all purgative medicines from the com- 
mencement in cases of intussusception." The bowel being 
incarcerated, the stimulus of purgation proceeding from above 
downwards is quite unable to undo the incarceration of an 
intussusception. A purgative acts injuriously as a stimulus 
which cannot be obeyed ; and its obvious tendency is to in- 
crease the peristaltic action of the bowels, and therefore to 
increase still more the invagination. That such is the case 
will be readily understood by a physiological consideration 
of the phenomena of intussuception : for although it is not 
always easy to account for the first beginning of invagina- 
tion, yet physiology enables us to understand how an invagi- 
nation once begun, the lesion tends to increase — (i.) From 
the peristaltic action of the bowel, gently stimulated and in- 
creased by irritation of every kind, so long as tonic irritability 
continues. (2.) From the spasmodic action of the part of the 
gut above the invagination, preventing spontaneous return. 
(3.) From the invagination being thus completed, it continues 
permanent, tenesmus occurs, and the violent and repeated 



220 INTESTINES, OBSTRUCTION OF. 

contractions of the abdominal muscles tend still more to 
maintain and increase the lesion. The constant motion and 
pressure of parts one upon another in some cases is so great 
that the end of the invagination has been known to penetrate 
through the walls of the inclosing bowel, so as to appear in 
the cavity of the peritoneum. The chief indications are — 
(i.) To prevent distension, by reducing, in every possible way, 
the quantity of food and drink, restricting the latter to 
small but frequent sips (preferably through a long straw or 
tube) of cool iced liquids. Food is to be given, as strong 
beef-tea, soup, or milk, with equal frequency and caution. 
Small doses of alcohol (as brandy with water, or soda-water) 
is to be alternated. But if any repugnance exists to food or 
drink, or if vomiting is excited by these articles, the amount 
given must be reduced. Water, milk, and gruel are to be 
given freely in often-repeated enemata. (2.) To assuage 
pain and to mitigate excessive peristalsis suggest the same 
kind of remedy — namely, opium, which is to be given con- 
tinuously and alone in the solid form, preferably as an ex- 
tract. The limit of the dose is indicated by the comparative 
arrest of pain, the approach of narcotism, and decided con- 
traction ot the pupil. Belladonna is only of use as a remedy 
to diminish the straining peristalsis. It may be given com- 
bined with opium, as two parts of extract of opium to one, 
two-thirds, or even one-half part of extract of belladonna in 
a pill Enemata are useful as a mechanical aid to removing 
obstruction. They may gradually distend the bowel at the 
site of obstruction, so as to effect such a change in its posi- 
tion and arrangement as may release the impacted portion. 
The administration of enemata is only safe and efficient if 
undertaken by a person of competent skill. The quantity 
of fluid must be injected little by little, and must be retained 
as long as possible ; and the patient must resolve to tolerate 
some pain in reaching the climax of distension at which only 
enemata are calculated to relieve obstruction. In cases 
where the intussusception is in the large intestine, inflation 
of the bowel with air, as originally suggested by Hippocrates 
two thousand years ago, in his third book, has of 
late years been revived and adopted, first in America, and 
subsequently in this country (Gorham, in Guy's Hospital 
Reports, and Med.-Chir. Trans., Vol. IX.) This Hippo- 
cratic remedy has undoubtedly been more successful than any 
other. Of twenty-eight cases, the details of which were col- 
lected by Dr. Osborne, there were only seven recoveries; and 



INTESTINES, OBSTRUCTION OF. 221 

three ot these were effected by inflation of the colon with air. 
Dr. Murphy and Mr. Erichsen have borne strong testimony 
to its value in discussion on the subject ; and the former 
had recourse to the operation on one of his own children 
with success (MS. Notes of Dr. Osborne). For its success, 
the remedy should be employed at an early period, before 
there has been time for adhesion between the contiguous sur- 
face of the volvulus. My friend, Dr. David Greig, of Dun- 
dee, has had recourse to this method of treatment in numer- 
ous instances with perfect success, and has published an ac- 
count of his experience in the Edin. Monthly Med. Journal 
October, 1864. By means of the ordinary elastic enema 
tube, fitted to the pipe of a small pair of bellows, he was able 
to pass a considerable quantity of air into the rectum, con- 
tinuing the process till the belly showed signs of considerable 
distention, and even till uneasiness prevailed. Its beneficial 
action is indicated by relief of the urgent symptoms, such as 
straining and vomiting ; and gradually a faecal evacuation is 
obtained from the bowels. At the same time warm fomenta- 
tions are to be applied to the belly. The use of large ene- 
mata, with manipulation, has also been recommended. A 
long stomach-tube is to be passed as high up the colon as it 
will go, and the anus being firmly compressed round it, warm 
water is to be slowly injected, so as to distend the bowel as 
much as possible. When the fluid is allowed to come away, 
the abdomen should be pressed upon with the hands, so as to 
move about the coils of intestine (Tanner). The earlier any 
of these remedies are had recourse to, the greater will be the 
chances of recovery; and the patient may be put under the 
influence of chloroform to facilitate the manipulations. 
Gastrotomy, abdominal section, or, as it is now called, 
laparotomy, has been successful in many cases, where other 
remedies have failed to give relief. Dr. Hilton Fagge and 
Mr. Howse have related such a case (Med.-Chir., Trans., 
Vol. LIX., 1876). The operation was advocated by Benja- 
min Phillips (see his paper in Med.-Chir. Trans., Vol. XXXI.) 
The cases for which it seems suitable are in obstructions 
from bands, diverticula, also intussusception, and the like 
lesions affecting the small intestine. The object of the oper- 
ation is to divide the cord-like cause of strangulation (Brin- 
ton); or to undo an invagination, all of which may be now 
easily accomplished under the antiseptic spray. If the 
bowels be much distended with air they may be punctured 
with a small trocar and canula. Stercoraceous accumula- 



222 ISCHURIA RENALIS JAUNDICE. 

tions must be mechanically removed. Repeated enemata of 
warm water, delivered through a long tube, will gradually 
permeate and disintegrate the mass ; and when it begins to 
break up, continued 3 ii. doses of Epsom salts, with a grain 
of quinine, in aromatic sulphuric acid and infusion of gentian 
will gradually bring the bowels to a normal state of activity 

Ischuria Reiialis — See Urine, Suppression of. 

Itch — See Scabies. 

Jaundice — Definition. — Certain morbid conditions in 
which many of the different tissues and fluids of the body 
are dyed yellow, or otherwise discolored, more especially the 
conjunctiva and the connective-tissue, from the coloring 
matter of the bile. 

Treatment. — As a general principle, the larger number of 
cases of jaundice from functional disorder (perhaps four out 
of five) get well spontaneously, aided by remedies judiciously 
selected according to the diagnosis already indicated. The 
first indication is to aim at removing the exciting cause; and 
in jaundice due to congestion of the liver, purgatives seem 
to act beneficially in the form of blue pill or Plummer's pill 
with aloes, and mix vomica with rhubarb pill mass. In cases 
of acute jaundice — from suppression of the biliary secretion 
consequent on a powerful nervous shock or mental perturba- 
tion — Dr. Anstie has seen two or three doses of hydrochlor- 
ate of ammonia, to the extent of grs. xx. every four hours, 
produce a restoration of the biliary secretion. He regards 
it as a most powerful restorative of the biliary functions. 
Acids and alkalies are alike contra-indicated in cases of 
jaundice resulting from active congestion of the liver. Ben- 
zoic acid has been recommended ; and Dr. Harley has found 
it useful in cases of suppression of bile (by innervation, for 
example); but in cases of jaundice from obstruction it is 
injurious. Podophyllin is also of use in jaundice from sup- 
pressed secretion of bile. It ought to be combined with 
hyoscyamus. It is especially useful in the cases of feeble 
liver, combined with vegetable tonics, such as gentian and 
quinine ; but it ought not to be given in cases of jaundice 
from obstruction. The medicine of all others which has 
seemed most generally useful is sulphate of magnesia, in half 
drachm to drachm doses, combined with fifteen grains of car- 
bonate of magnesia, and half a drachm of aromatic spirits of 
ammonia, given three times a day an hour before food. The 
sulphate of magnesia maintains a free action of the bowels ; 



KELOID LARYNGISMUS STRIDULUS. 223 

and the carbonate of magnesia neutralizes any excess of acid 
in the stomach or bowels. 

Keloid — See Cheloid. 

Kidney, AbSCeSS Of— See Nephritis, Suppurative. 

Kidney, Floating — Definition. — A floating kidney is a 
condition in which the kidney has a mesentery or fold of peri- 
toneum attaching it very loosely to the spine, by which it 
can be moved about to the extent of the length of its mesen- 
tery. A movable kidney merely slips a little under the 
fingers. 

Treatment. — Wearing a tolerably tight, elastic abdominal 
bandage may completely remove the abnormal condition, 
and will at least relieve the dragging and uneasy sensations. 
Constriction of the thorax at the lower part by stays or 
waistbands must be avoided. Constipation and the conse- 
quent straining, as invariably aggravating the mischief, must 
be relieved. Treatment generally must be of a tonic nature 
(Sawyer, 1. c.) 

Laryngismus Stridulus — Definition. — A paroxysmal 
spasmodic disease in which the muscles of the glottis are 
contracted, the vocal cords tightly stretched and so approx- 
imated that the glottis is for a time partially or completely 
closed. In the latter case there is arrest of the respiratory 
movements and apnoea. In the former case there is stridu- 
lus inspiration and dyspnoea. The affection depends upon 
some morbid excitement of the par vagum and its nerve 
centres, direct or reflex, and is usually seen in infants, 
especially during the period of first dentition, and in children 
before the completion of the second year ; and in the great 
majority of cases between the fourth and tenth month. It is 
also seen in adults. 

Treatment. — Two important indications have been fulfilled 
in carrying out the treatment — -viz., the relief of the parox- 
ysm, and the removal of the morbid condition, whether local 
or general, which gave rise to it. 

" The immediate treatment generally falls to the nurse or 
mother. The little patient should be raised and placed in a 
sitting posture, and then he may be slapped on the back, 
cold water may be dashed in the face, and ammonia or 
strong acetic acid held to the nose. These measures are 
often successful by giving rise to violent expiratory actions ; 
but remedies calculated to relieve spasms are equally sue- 



224 LARYNGISMUS STRIDULUS. 

cessful. The warm bath may be used and emetics given 
directly there is a sign of the stridor — when the paroxysm is 
on, the child will not drink. A favorite remedy in Germany, 
and one that is highly successful, is tickling the fauces with 
the finger or a feather until vomiting is produced. Depres- 
sing enemeta, such as tobacco, have likewise been recom- 
mended, but their use is attended with considerable danger. 
The ordinary rules for the treatment of disease apply here ; 
that is to say, gentle remedies should be used in mild cases, 
and those of a more powerful character in dangerous ones. 
Putting the lower part of the child's body in a hot bath and 
dashing cold water in its face, is a simple and sometimes suc- 
cessful plan. The inhalation of chloroform is a very valua- 
ble remedy, but of course, must be used with great care, and 
cannot safely be employed by non-professional persons. If 
the child appears to be sinking from the apncea, the trachea 
must, of course, be opened, and artificial respiration resorted 
to. Indeed this should even be adopted by the practitioner 
should he arrive shortly after the apparent extinction of life. 
Some practitioners recommend the use of antispasmodic 
remedies (whether animal, vegetable, or mineral) between 
the fits" (Morell Mackenzie). 

Where the exciting cause of the attack can be traced to 
dentition, the gums should be lanced ; if the affection should 
appear to be due to intestinal derangement, means must be 
taken to remove any source of irritation from the alimen- 
tary canal, and for this purpose perhaps the best remedy is 
a dose of castor-oil. Thymic enlargement should be treated 
by the application of leeches (according to the patient's age 
and strength), and afterwards by counter-irritation. As re- 
gards the constitutional state predisposing to disease, suitable 
treatment will be found detailed in the various articles in 
these volumes which treat of scrofula, rickets, hydrocepha- 
lus, parasites, and the like. Spasm of the glottis has hither- 
to been treated as an infantile disorder, but it sometimes oc- 
curs in adults. It is usually met Avith in women, and is 
commonly regarded as hysterical. In these cases, sedative 
inhalations (which cannot well be used in the treatment of 
children) generally give prompt relief. 

During the intervals of paroxysm means must be taken 
to prevent its recurrence. These mainly consist of atten- 
tion to the state of the alimentary canal. A searching 
purgative is generally called for to clear out the contents of 
the bowels-^calomel, jalap, and castor-oil are the most use- 



LARYNGITIS. 225 

ful agents. Belladonna, to the extent of one-sixth of a 
grain thrice daily, combined with bromide of potassium or 
of ammonium, may be of use. Sinapisms and liniments 
are also of use. The diet ought to be carefully regulated. 
Change of air is generally called for, and the tepid and cold 
bath must be in daily use. 

Laryngitis. — Definition. — Inflammation of the lining 
membrane of the larynx. 

Treatment. — In its early stages a warm, moist, and uniform 
temperature, with complete rest of the parts, is of the first 
importance. Not only should all use of the voice be inter- 
dicted, but the tendency to cough should as much as possi- 
ble be arrested by the administration of small doses of mor- 
phia, especially in those cases in which paroxysmal cough is 
a prominent symptom. Inhalations of hot steam, or steam 
impregnated with the volatile principles of benzoin, hops, or 
conium, are of the greatest service. Plot poultices and 
fomentations may also be ordered. Neither local nor general 
blood-letting, blistering, mercury, antimony, nor other low- 
ering remedies are to be recommended; after the acute symp- 
toms have passed off, astringent solutions may be applied to 
the larynx to hasten a cure. 

In children, a warm moist temperature, poultices, warm 
emulcent drinks, and if there is much dyspnoea, emetics of 
sulphate of copper or sulphate of zinc, are the most 
serviceable methods of treatment. When laryngitis oc- 
curs in a subacute form, or shows a tendency to become 
chronic, a regular system of inhaling should be prescribed. 
Any of the appended forms may be employed ; and there 
are many others contained in the very useful Pharmacopoeia 
of the Hospital for Diseases of the Throat, published by 
Churchill, 187 1. For the admistration of the following rem- 
edies, the Eclectic Inhaler possesses great advantages; for 
whilst the vapor to be inhaled is thoroughly saturated with 
the volatile principles employed, and is kept at a uniform tem- 
pgrature, the patient is able to inhale without effort. [It can 
be obtained of Messrs. Bullock & Reynolds, 3 Hanover 
Street, Hanover Square, London ; or of Maw, Son, & 
Thomson, London.] The inhaler devised by Dr. James 
Adams, of Glasgow, is also to be commended. 

5&. Creasoti, fl. dr. iij.; Glycerine, fl. dr. iij.; Aquae ad. fl. 
oz. iij.; mix. A teaspoonful to be added to a pint of water 
at 150° Fahr , and inhaled for five minutes twice or thrice 
daily. 

15 



226 LARYNGITIS. 

01. Pini. Sylvestris, fl. dr. ij.-iij.; Mag. Carb. Lev. gr. 60- 
90 ; Aquae ad. fl. oz. iij.; mix., and use as above. 

In addition Oil of Juniper, fl. dr. L, ad. fl. oz. iij.; Oil of 
Santal, m xv.; Oil of Myrtle, mxx., are all of service. 

It will be found convenient to prescribe light carbonate of 
magnesia as a medium, in the proportion of one grain to 
every two minims of the oil ; and the addition of twenty 
grains of camphor to any of the above makes the inhala- 
tion additionally stimulative. When layrngitis is asso- 
ciated with inflammation of the pharynx, lozenges con- 
taining guaiacum are very useful in removing the hy- 
peraemic condition. Even when the pharynx is not affected, 
the experiments of Fournie have proved that lozenges have a 
decidedly beneficial effect on diseases of the larynx. It is nec- 
essary after an attack of acute laryngitis to caution a patient 
that he is very liable to a recurrence of this affection, and that 
he should therefore be very careful to guard against all prevent- 
ible causes of the disease. As laryngitis is more common to 
those engaged in in-door than out-door occupations, and 
those living in towns than in the country, Niemeyer recom- 
mends out-of-door exercise, with proper precautions, as a 
valuable prophylactic measure. Acute laryngitis sometimes 
occurs as a complication of erysipelas ; but erysipelatous in- 
flammation of the larynx originating in that part is rare. 
The local treatment should at first be directed towards ar- 
resting the inflammation, by sucking ice, &c; but when the 
morbid process is advanced, the treatment is the same as that 
required for ordinary acute laryngitis. The constitutional 
treatment should be that applicable to other forms of erysip- 
elas. Tracheotomy, although offering a less favorable chance 
than in the simple laryngitis, should be performed if the 
symptoms are urgent. Of the other catarrhal forms of 
laryngitis may be mentioned those of measles and scarlati- 
na. In measles the affection of the larynx may be either a 
simple catarrh, or a simple diphtheritic affection. The catar- 
rhal form may occur before the eruption appears, a day or 
two after the rash has come out, or when it is beginning 
to decline. Although the inflammation is often severe, it is 
seldom sufficient to cause anxiety. The diphtheritic form is 
much less common, and " seldom begins until the eruption of 
measles is on the decline, or the process of desquamation 
has commenced. Its appearance is most frequent from the 
third to the sixth day after the appearance of the eruption ; 
but it oftener occurs at a later than at an earlier period " 



LARYNGITIS. 227 

(West). The treatment should be the same as that for pri- 
mary croup. In scarlatina the laryngitis may be either cede- 
matous or croupous : they are fortunately both rare compli- 
cations. The cedematous form may be one of the manifes- 
tations of the exanthem, or may be dependent on debility, 
or it may be due to the renal affection, which is so common 
a sequel of scarlatina. The croupy form is not common, 
and seems to have been peculiar to some epidemics. In all 
cases of laryngitis associated with scarlatina, there is a great 
tendency to the ulcerative process. The treatment required 
is of a tonic and nourishing character, with the free use of 
well-diluted stimulants. Tracheotomy may be necessary when 
there is oedema ; but scarification should always be first tried. 

In all cases of oedema of the larynx, whatever the cause, 
scarification and hot steam inhalations, as recommended 
in acute laryngitis, are the most serviceable aids. 
When suffocation is imminent, tracheotomy should be per- 
formed. 

Applications of mineral astringents to the larynx, either 
with the laryngeal brush, or in the form of atomized 
inhalations, are of the greatest service ; and the " alterna- 
tion of topical remedies is often as efficacious in the 
cure of chronic laryngitis as it is in the treatment of chronic 
inflammation of other mucous passages." Although Nie- 
meyer is of opinion that " induration of the submucous tissue 
(of the larynx) is incapable of resolution," it is the daily ex- 
perience that local treatment of chronic thickening of this 
region, unless, indeed, it be due to phthisis, is attended with 
the very best results. Stimulating inhalations may be used 
with great benefit. " Amongst the remedies I have found 
most efficacious," writes Dr. Morell-Mackenzie, "are solutions 
of perchloride of iron (gr. 60-120 ad. fl. oz. i.), chloride of 
zinc (gr. 20-30 ad fl. oz. 1), sulphate of copper (gr. 15 ad fl. 
oz. i.), sulphate of zinc (gr. 5 ad. fl. oz. i.), alum (gr. 30-60 
ad fl. oz. i.), chloride of aluminium (gr. 30-60 ad fl. oz. i.). 
The perchloride of iron and chloride of zinc are the solutions 
I use most largely. Glycerine will also be found a most use- 
ful solvent for these agents, as its consistence is better cal- 
culated than that of water to keep up prolonged and close 
contact between the remedy and the affected membrane. I 
seldom employ solutions cf nitrate of silver as applications 
to the larynx, for whilst I have not found them more bene- 
ficial than other mineral astringents, they are much more 
likely to produce spasm and nausea " (Use of the Laryn- 



228 LARYNGITIS. 

goscope, third edition, page 98). Of atomized solutions, 
those of tannin (gr. 5 ad fl. oz. i.), and perchloride of iron 
(gr. 2 ad fl. oz. i,) are most useful. Bergson's Atomizer, 
known in this country under the name of Andrew Clark's 
Spray Producer, Dr. Richardson's Ether Spray Apparatus, 
and Dr. James Adam's Siegle's Inhaler, are the most con- 
venient for administering atomized liquids. Functional rest 
is, of course, of great importance in those cases of chronic 
laryngitis in which the voice is much affected. If complete 
silence cannot be enforced, the patient should be recom- 
mended to speak only in a whisper. Relaxation of the 
uvula, being a frequent cause of irritation of the larynx, 
should be treated by astringent lozenges of tannin, rhatany, 
or kino; and if necessary the elongated part should be cut 
off. A warm dry climate is of essential service in obstinate 
cases of chronic inflammation of the larynx; as are also 
some mineral waters, particularly those of Ems, Ober-Salz- 
brunnen, Les Eaux Bonnes, Luchon, Cauterets, Aix-les- 
Bains. 

Besides the common form above described, there are cer- 
tain varieties of chronic laryngitis to which it will be neces- 
sary to give a brief consideration. These are — first, those 
due to a morbid state of some special tissue of the larynx; 
and, secondly, those due to a morbid condition of the general 
system, and mainly dependent on constitutional causes. Of 
the former, we have glandular laryngitis and phlebectasis 
laryngea; of the latter, syphilitic laryngitis and laryngeal 
phthisis. 

Chronic glandular laryngitis, or chronic inflammation of 
the minute racemose glands of the larynx, is generally asso- 
ciated with disease of the follicles of the pharynx and tonsils; 
but, as the glandular of the larynx are all of the racemose 
character, it is better to use the generic term " glandular 
laryngitis." It is this disease which has most improperly re- 
ceived the name of dysphonia clericorum, or clergymen's sore 
throat. The most common throat affection of the clergy is 
not, however, glandular pharyngitis or laryngitis, but merely 
chronic inflammation of the pharynx and larynx, with paresis 
of the laryngeal muscles. Glandular laryngitis, on the other 
hand, is not at all peculiar to those whose profession requires 
them to make sustained use of the voice, but generally occurs 
in people of feeble constitutional powers. 

The symptoms are similar to those of ordinary chronic 
laryngitis, but the disease is more intractable. There is a 



LARYNX, ABSCESS OF. 229 

constant sensation of a foreign body in the throat, and ? 
corresponding disposition to hawk and clear the throat, 
With the laryngoscope, the enlarged orifices of the laryngeal 
glands may sometimes be made out. Pathologically, the dis- 
ease is essentially one of the secretory system, the normal 
secretion of the minute racemose glands, instead of being 
clear and transparent, becoming thick, white, and opaque. 
By some observers it is thought to be due to imperfect or 
perverted digestion; but it is more probable that the glan- 
dular of the stomach are simultaneously affected. 

The treatment is the same as that recommended for simple 
chronic laryngitis, except that the use of strong solutions of 
nitrate of silver is more often indicated than in that affection. 
There is frequently considerable feebleness of the voice, in 
which case stimulating inhalations and the application of 
electricity are the appropriate measures. 

The second variety, that of phlebectasis laryngea, first de- 
scribed by Dr. Morell-Mackenzie {Lancet, July 6, 1862), 
consists of a venous congestion of the larynx. It is very 
uncommon. The symptoms are slight and usually consist 
in no more than an uneasy sensation in the larynx, and a 
more or less frequent cough. With the laryngoscope, dark 
vessels may be seen on various parts of the larynx, particu- 
larly on the ventricular bands. The treatment consists in the 
destruction of the vessels by the electric cautery, and the 
use of vigorous constitutional remedies. 

The varieties of syphilitic laryngitis and phthisical laryn- 
gitis depend on a special constitutional condition, and will 
be treated under Larynx, Ulcer of 

Larynx, Abscess Of. — Definition. — Death of the cartila- 
ges, by a molecular or truly carious process, usually preceded 
by separation of the perichondrium, and sometimes attended 
with circumscribed collections of pus. 

Treatment. — The practitioner's treatment must be directed 
to the relief of the pain, the dyspnoea, and the dysphagia. 
For the former, subcutaneous injections of morphia should 
be administered. The dyspncea may be such as to render 
tracheotomy necessary; and in cases where the dysphagia 
is extreme (as nothing can be done to actually dilate the 
narrowed oesophagus) the patient must be fed by enemata 
or the oesophagus tube. The preferable way, in cases which 
will admit of it, is to use an oesophageal tube with a feeding- 
bottle attached. By means of an instrument of this kind, in 



230 LARYNX, BENIGH GROWTHS IN. 

one of the cases referred to, the patient's life was sustained 
for more than three months ; and after death there was a 
considerable layer of fat covering the body. Of course, great 
care must be taken in passing the tube ; but where practicable, 
this method of feeding is far more satisfactory in every re- 
spect than the use of enemata per rectum. 

Larynx, Benign Growths in. — Definition. — New for- 
mations of benign character, forming projections on the 
mucous membrane of the larynx, generally giving rise to 
aphonia or dysphonia, often to dyspnoea, and occasionally 
to dysphagia. 

Treatment, — In cases where the growth is small, does not 
appear to increase, and does not give rise to functional de- 
rangement, no treatment need be adopted. Where the op- 
posite conditions, however, exist, means should at once be 
taken to eradicate the growth, or to place the patient out of 
danger by performing tracheotomy. Radical treatment may 
be divided into internal, that is, removal or destruction of 
the growth through the mouth with the aid of the laryngo- 
scope ; or external, by operations through the neck. Inter- 
nal treatment may be further subdivided into Mechanical 
and Chemical. Mechanical traatment consists in evulsion, 
by common laryngeal forceps, tube forceps, ecraseurs, or 
guillotines. Added to this, there are a few cases in which 
crushing or incision of the base of the growth is effectual. 
Chemical treatment consists in the application of various 
caustic solutions, — a process seldom satisfactory — and in gal- 
vanic cautery. This last method has been very successful 
in the hands of some Continental practitioners ; but it can- 
not be recommended, on account of the complicated and 
unwieldy apparatus required by the practitioner, and of the 
great pain often experienced by the patient. External treat- 
ment may be divided into thyrotomy, or division of the thy- 
roid cartilage, supra-thyroid laryngotomy , or division of the 
thyro-hyoid membrane, and infra-thyroid laryngotomy, or re- 
moval of the growth through the crico-thyroid membrane, 
or by an opening made in the trachea. In addition to these 
various surgical procedures, there is the combined method, 
in which tracheotomy having been called for, on account of 
the urgency of the symptoms, the neoplasm is afterwards re- 
moved per vias naturales. All external measures are attended 
with less satisfactory results, both as to life and restoration 
of function, than those resulting from laryngoscope treat- 
ment : and it should be borne in mind that the more serious 



LARYNX, CONTRACTION OF. 231 

surgical methods should never be resorted to unless the tu- 
mor in the larynx produces symptoms endangering the life 
of the patient. 

Larynx, Contraction of. — Definition-Narrowing of the 
passage of the larynx, the result of various lesions. 

The Treatment of narrowing of the larynx resolves itself 
sooner or later into tracheotomy. In cases of syphilitic ci- 
catricial thickening, iodide of potassium does little good, and 
local treatment is oY no avail. In chronic tubercular nar- 
rowing, treatment is equally futile. In all cases, if the dys- 
pnoea is extreme, tracheotomy must be performed at once, 
and measures can subsequently be taken for dilating the 
contracted passage by any of the mechanical devices which 
have been invented for the purpose. 

Larynx and Pharynx, Treatment of by Atomized 
Fluids. — The treatment of diseases of the pharynx and of 
the larynx by the use of atomized or spray-producing fluids, 
in which medicated vapor and gases are brought to act upon 
the parts, has received a great impetus since better appli- 
ances have been devised for using such remedial agents. The 
aim of such instruments is to atomize or pulverize, or very 
minutely to divide the fluid, by causing it to be thrown as a 
fine shower or spray, so as to be inhaled as such by the pa- 
tient. Dr. Andrew Clark's hand-balls, fitted with Bergoon's 
tubes and Maunder's atomizer, constitute an efficient and 
useful arrangement for applying fluids in this way up the 
nostrils, to the back of the throat, or over the entrance to 
the larynx (Da Costa). Dr. Richardson's well-known in- 
strument for the production of local anaesthesia is also an ex- 
cellent atomizer of fluid, and may be used for a similar pur- 
pose. 

Where it is desirable to make the topical application di- 
rectly upon the diseased part, these are the most simple in- 
struments that can be used without loss of time by the phy- 
sician; but where inhalation simply of vapor or heated air 
variously medicated is all that is required, nothing can be 
better than that used by Dr. Fergus, of Glasgow; or an im- 
proved apparatus for spray inhalations devised by Dr. James 
Adams of Glasgow. 

Siegle's apparatus, and Dr. Morell-Mackenzie's elecjric 
inhaler, and Martindale's portable inhaler, are all of them 
useful and valuable instruments for inhalation of suitable 
remedies. 



232 LARYNX AND PHARYNX, TREATMENT OF. 

On this most useful mode of treatment Dr. Da Costa 
makes the following observations. "(1.) Inhalations by 
means of atomized fluids are an unquestionable addition to 
our therapeutic means; but they are nothing but an addition, 
and not a substitute for all other treatment. (2.) In most 
acute diseases of the larynx, and still more so in acute disor- 
ders of the lungs, their value, save in so far as those of water 
may tend to relieve the sense of distress, &c, and aid expec- 
toration, is very doubtful; though in some acute affections, 
such as in oedema of the glottis and in croup, medicated in- 
halations have strong claims to consideration. (3.) In cer- 
tain chronic morbid states of the larynx, particularly those 
of a catarrhal kind, and in chronic bronchitis, they have 
proved of great value. (4.) In the earlier stages of phthisis, 
too, they may be of decided advantage; and at any stage 
they may be a valuable aid in treating the symptoms of this 
malady. (5.) Their influence on such affections as hoop- 
ing-cough and asthma is not satisfactorily proved. (6.) 
They furnish a decided and unexpected augmentation of our 
resources in the treatment of pulmonary haemorrhage. (7.) 
They require care in their employment; and in acute affec- 
tions Ave should consider whether, as they have to be used 
frequently to be of service, the patient's strength justifies the 
disturbance or the annoyance their frequent use may cause. 
(8.) In any case, to be of service, they ought to be carried 
on as a treatment with a distinct object, and not intermit- 
tingly or spasmodically resorted to." 

Table of doses for Inhalation (Da Costa; (1.) Alum, 10 
to 20 grains, to 1 fluid ounce of distilled water. Suitable in 
chronic catarrhal states of the pharynx and air-tubes, partic- 
ularly in bronchial affections with excessive secretion, when, 
as in most inflammatory conditions of the respiratory mucous 
membrane, it may be advantageously united with opium. In 
a somewhat stronger solution, 30 grains to the ounce, it is 
useful in pulmonary haemorrhage. As an astringent, it is 
generally more of a sedative, and more suited to conditions 
of irritation than tannin (Fieber). (2.) Tannin, 1 to 20 
grains. — Useful for the same affections as alum. Employed 
in cases of laryngeal ulceration and excrescences, in oedema 
of the glottis (Trousseau), and in croup. Here, as well as 
in pulmonary haemorrhages, it is used in large doses. In 
ordinary cases of laryngeal or bronchial disease, it is well 
to commence with a comparatively weak solution — 5 grains 
to 1 fluid ounce of water. If the remedy occasion much heat 



LARYNX AND PHARYNX, TREATMENT OF. 233 

and dryness, its use should be discontinued. (3.) Iron (per- 
chloride of), I to 2 grains. — In earlier stages of phthisis; in 
chronic pharyngitis or laryngitis it may be used in a stronger 
form — 3 grains to 1 fluid ounce of water. As a weak inha- 
lation, it is useful in hysterical aphonia. Stronger solutions 
— 2 to 10 grains to the ounce — are useful in pulmonary 
haemorrhage. In ordinary cases in which we wish a non- 
astringent salt of iron, the lactate, citrate, or phosphate may 
be also used, though they are not, on the whole, as available 
as the chloride. (4.) N itrate of silver, 1 to 10 grains. — Is 
useful in ulcerations of pharynx and larynx, and in follicu- 
lar pharyngitis. A face-shield is always to be used. 10 
grains to the ounce only to be used in cases of ulceration. 
(5.) Sulphate of zinc, 1 to 6 grains. — In bronchial catarrh 
with excessive secretion ; in aphonia connected with chronic 
laryngeal catarrh. The Chloride of Zinc (2 to 5 grains) is 
also useful in the same conditions. (6.) Chloride of Sodium, 
5 to 20 grains. — Promotes expectoration and diminishes 
sputa ; employed in phthisis. (7.) Chlorinated Soda (Liquor 
Sodae Chlorinatae), ^ to 1 drachm. — In bronchitis with of- 
fensive and copious expectoration ; in phthisis. (8.) Chlor- 
ide of Ammonium, 10 to 20 grains. — In laryngeal and bron- 
chial catarrh, acute as well as chronic, to promote expector- 
ation ; also in capillary bronchitis. The dose best borne is 
not above 10 grains to the ounce. (9.) Opium (watery ex- 
tract of), ^ to ^ a grain. — In irritative coughs, and as an 
adjunct to allay irritation. Also for its constitutional ef- 
fects. Dose of tincture of opium 3 to 10 drops. Acetate of 
morphia, one-twelfth to one-eighth of a grain, has been ad- 
ministered ; but large doses require much caution. (10.) 
Conium (fluid extract of), 3 to 8 minims. — Irritative cough; 
asthma ; feeling of irritation in larynx, (n.) Hyoscyamus 
(fluid extract of), 3 to 10 minims. — Spasmodic cough ; 
hooping-cough. One-half grain of the extract, gradually 
increased ; or the tincture may be employed. (12.) Canna- 
bis Indica (tincture of), 5 to 10 minims. — In spasmodic 
cough and phthisis. (13.) Iodine, 2 to 15 minims of the 
tincture. — In chronic bronchitis, phthisis, functional aphonia 
and hay asthma. (14.) Arsenic (Liq. Arsenicalis). 1 to 20 
minims. — Nervous asthma (Trousseau). (15.) Tar Water, 1 
to 2 drachms of officinal solution. — In offensive secretions 
from bronchial tubes ; in tuberculosis ; as an antiseptic in 
gangrene of lungs. (16.) Turpentine, 1 to 2 minims. — In 
chronic bronchitis with offensive secretions ; in bronchor- 



234 LARYNX, ULCER OF THE. 

rhoea ; in gangrene of lungs. (17.) Lime Water, used of of- 
ficinal strength, or stronger. — In diphtheria ; in membranous 
croup. (18.) Water, Distilled. — Cold, in pulmonary haemor- 
rhage ; warm water in asthma ; in croup ; and in bronchitis. 
For various other modes of applying tropical applications 
to the larynx, the student is referred to Dr. Morell-Macken- 
zie's work On the Laryngoscope. 

Larynx, Ulcer of the. — Definition. — Loss of substance 
of the larnyx, in rare cases the result of simple inflammation, 
caused either by syphilis or phthisis. 

(a.) Syphilitic Ulceration. 

Treatment. — Secondary laryngeal affections are sometimes 
difficult to cure, but after undergoing certain phases of evo- 
lution they may disappear spontaneously. If allowed to 
run their natural course, condylomata generally disappear at 
the end of two or three months, but chronic congestion is 
more intractable. Stimulating inhalations, and the local ap- 
plication of astringents are sometimes of great service. Ul- 
ceration of the larynx (secondary) is seldom so severe as to 
require the application of solid nitrate of silver. In tertiary 
laryngeal syphilis, large doses of iodide of potassium, in 
combination with ammonia, and freely diluted with water, 
are of the greatest use ; but local treatment is also of the 
first importance. The application of solid nitrate of silver, 
or of strong solutions of the same salt (60 gr. ad fl. oz. i.), 
or of sulphate of copper (15 gr. ad. fl. oz. i.), is attended 
with the most satisfactory results. For applying the solid 
nitrate the method of fusing a very small portion of the salt 
on to a curved aluminium wire far surpasses, in simplicity 
and safety, any other form of laryngeal porte-caustique. 

(b.) Phthisical or so-called Tubercular Ulceration of the 

Larynx. 
Ln the treatment of phthisical ulceration, remedies similar 
to those recommended for chronic laryngitis may be employed 
with advantage. Mineral astringents have a beneficial effect 
in the early stages, and are useful in relieving the dysphagia 
when ulceration of the epiglottis has taken place. Sedatives, 
whether in the form of inhalations or as medicines which al- 
lay the cough, and so keep the larynx at rest, are also to be 
recommended. Treatment, however, is at the best but pal- 
liative. Every effort should therefore be made to carry out 
preventive measures. Congestion of the larynx in patients 



LEAD PALSY. 235 

of a phthisical tendency, should be treated with the greatest 
promptitude — first, by proper local treatment; secondly, by 
complete rest of the voice; thirdly, by a suitable climate — a 
warm, dry, and uniform temperature being most to be com- 
mended. The constitutional treatment required is similar 
to that which will be found described under " Pulmonary 
Phthisis." 

Lead Palsy. — Definition. — A series of morbid phenome- 
na induced by the absorption of the salts of lead contained 
in solution in drinking-waters, or in various foods and 
drinks, or conveyed into the system through the integuments 
of those who are in the habit of handling the soluble salts of 
lead; or through the pulmonary mucous membrane of those 
exposed to the influence of vapors containing lead. 

Treati?ie7it. — The objects to be obtained in the treatment 
of lead colic are to procure stools, a copious discharge of 
urine, and perspiration, with a view of eliminating the poison 
from the body. To allay pain is also an urgent necessity. 
For these purposes five grains of calomel, fifteen grains of 
jalap, and one grain of opium, should be administered as 
soon as the patient is seen; and at the end of two hours 
about two ounces of camphor mixture, combined with a 
drachm or two drachms of sulphate of magnesia, and twenty 
minims of tincture of hyoscyamus may be given, and repeated 
every two or every four hours, till the bowels are freely evac- 
uated, when relief more or less complete is obtained. The 
mixture should be continued at proper intervals for three, 
four, or five days, when the patient, though greatly weakened, 
has in general recovered. In a few cases, however, the pain 
continues, and with considerable severity, after the bowels 
have been freely evacuated. The practice in these instances 
is to apply a blister to the epigastrium, and to keep the blis- 
ter open for a few hours. This additional application will 
generally complete the cure. The patient is also relieved if 
placed in a warm bath, and at the same time directed to in- 
ject repeated enemata of hot water, that stools may be readily 
obtained. In the absence of the warm bath, a large linseed 
or mustard poultice should be applied over the abdomen. 

With respect to the treatment of lead palsy, it has been 
believed that sulphur has the power of neutralizing the effects 
of lead by forming some innocuous compound with it. It is 
not known, however, whether any such compound is really 
formed; but lead poisoning in its chronic and constitutional 



236 LEAD PALSY. 

forms is more successfully treated by sulphur baths than by 
any other agent except iodide of potassium, to which they 
form a most important adjuvant. The ingredients of these 
baths consist of from two to four ounces of the sulphuret of 
potassium, mixed with from twenty to thirty gallons of wa- 
ter. The ergot of rye (secale cornutum) has been said to 
produce a considerable increase in the power of the flexor 
muscles of the arm in about a fortnight, and the improve- 
ment gradually extends to the flexors, till at the end of about 
three months the patient has recovered. This may have 
been the natural result of elimination of the lead. The ex- 
periments of Orfila long ago rendered it probable that lead is 
removed from the body by the kidneys; and iodide of po- 
tassium promotes the elimination of lead in this way. It may 
be used with advantage combined or not with the citrate of 
iron, the use of iron, in some form or other, having been 
found of benefit in cases of palsy from lead contamination. 
Dr. Parkes has chemically proved that lead can be made to 
pass off by the urine by the action of iodide of potassium, in 
the same way as mercury is known to be eliminated. The 
principle upon which the iodide of potassium acts is that the 
lead is in actual union with the affected tissues, being re- 
tained among them as an insoluble compound; and the iodide 
of potassium, after its absorption into the blood, combines 
with the lead, and forms with it a new and soluble salt. The 
poison is thus liberated from its union with the injured part, 
dissolved out from the damaged fibre, and once more set 
afloat in the circulation. Thus the poison and the remedy 
are cast out together by the urine (Melsens, William Budd). 
It is necessary, however, to notice the dangerous phenomena 
which may at first supervene on the administration of iodide 
of potassium in cases of lead poisoning; and great caution is 
necessary in the employment of this remedy in man for the 
first few days. At the moment when the metallic compounds 
fixed in the body become dissolved or transformed, the phe- 
nomena of acute poisoning may occur, caused by their lib- 
eration. So much is this the case, that the treatment may 
be supposed to be at first hurtful rather than beneficial. The 
patient should have beside him a graduated solution of the 
iodide of potassium; and should begin with a small dose (fif- 
teen grains during the twenty-four hours), and afterwards in- 
crease or diminish it according to his pains and sensations 
(Melsens). Dr. Fagge has also noticed that the administra- 
tion of iodide of potassium to a person poisoned by lead, is 



LEUCUCYTH^MIA. 237 

sometimes followed by the development of a line in the gums 
which had previously been absent, and this when the patient 
was removed from the influence of lead. 

Galvanism, in the form of Faradization, ought to be used 
as a local stimulant to the nerves, with the precaution that its 
application is not to be continued too long each time. Ten 
or fifteen minutes, at three different periods of the day, or of 
every second day, and persevered in for not less than four 
weeks, will be found of great service (Todd, Althaus). The 
beneficial influence will follow, although, in the commence- 
ment of the treatment, even a current of very high tension 
does not cause any movement whatever in the paralyzed mus- 
cles. In such cases the beneficial influence seems attributa- 
ble to the restoration of mobility to the molecules of nerve 
and muscle by an induced current, and which is necessary 
to enable them to be physiologically active. Severe shocks, 
especially in the commencement of the treatment, should 
therefore be carefully avoided, as by such the weakened ex- 
citability of nerve and muscle may be reduced, in place of 
being fostered and developed (Althaus, 1. c, pp. 112 and 
119). It would be rational, however, to defer the applica- 
tion of galvanism till the lead has been completely elim- 
inated. 

LeilCOCytliaemia — Definition — A disease sui generis, in 
which the number of white corpuscles in*he blood is greatly 
increased, with a simultaneous diminution of the red. This 
state is brought about by chronic exhausting diseases, expos- 
ure to cold and wet, or serious acute affections — such as 
typhus fever, pneumonia, puerperal fever, affections of the 
lymphatic glands or of the spleen, and is attended sometimes 
by cough or diarrhoea, epistaxis, hemorrhagic effusions, 
furunculus or pustulous eruptions. 

Treatment. — The most varied remedies have been tried 
without checking the increased formation of colorless cor- 
puscles ; but it is suggested that if it is possible to discover 
the glandular or splenic affection early, before the alteration 
of the blood has made much progress, it is probable that the 
disease may be averted. Tonics, nutrients, and stimulants, 
are indicated to support the system. The use of the nitro- 
muriatic bath ought not to be neglected, and the indications 
given under anaemia and chlorosis may be followed. Phos- 
phorus has been administered with some success by Drs. 
Broadbent and Wilson Fox. Sir William Jenner adminis- 
tered the drug in capsules containing one-thirtieth of a grain 



238 LEPROSY, TRUE. 

of phosphorus, two or three times a day for four months, 
without appreciable benefit to the patient. The results 
generally are unsatisfactory as regards any treatment of these 
cases. 

Leprosy, True — Definition — A constitutional, non-con- 
tagious, hereditary affection, essentially chronic in its nature, 
expressing itself mainly by shining tubercles of different sizes, 
of a dusky red or livid color, on the face, the ears (and often 
the extremities) — the skin being thickened, wrinkled, rough, 
unctuous, divested of hair, and the perspiration highly offen- 
sive — in which there is loss of feeling, or other disorder of 
innervation, and a tendency to ulceration death of the affected 
parts. The eyes in extreme cases are fierce and staring, and 
the voice is hoarse and nasal. 

Treatment. — The only hope of exterminating leprosy lies 
in the adoption of hygienic measures tending to improve 
the general conditions, physical and moral, of the leprous 
poor. Medicinal treatment is of no avail, unless combined 
with the regular use of a nutritive unstimulating diet, suita- 
ble clothing, protection against the vicissitudes of the weather, 
personal cleanliness, and exercise in the open air. The med- 
icines which have been found of most service are tonics and 
alteratives, especially preparations of iron and iodine. Mer- 
cury is extremely injurious. Arsenic has for centuries been 
held in high esteem in India as a remedy in true leprosy. It 
is given in the following combination: — 105 grains of arsen- 
ious acid are triturated with five or six times the quantity of 
black pepper. Thus made into a mass, it constitutes the 
material of the well-known " Tanjore pill," of which one the 
size of a " tare" is to be taken night and morning (Waring's 
Therapeutics, p no). The systematic use of baths, simple, 
saline, or sulphurated, are decidedly beneficial. Cupping- 
glasses or moxas, along the line of the spinal column, has 
been of marked advantage in relieving the lesions of inner- 
vation whether of increased or diminished sensibility. At 
a very early period of the inquiry carried out by the College 
of Physicians, the nature of the. replies received enabled the 
college to assure the Secretary of State for the colonies that 
" there was no evidence which, in their opinion, justified any 
recourse for the compulsory segregation of lepers." After 
receiving this decided opinion, the Duke of Newcastle forth- 
with issued a circular to the Governors of the Colonies, ex- 
pressing his opinion, " that any laws affecting the personal 
liberty of lepers ought to be repealed; and that, in the mean- 



LICHEN LIVER, ABSCESS OF. 239 

time, if they shall not be repealed, any action of the execu- 
tive government in enforcement of them, which is merely 
authorized and not enjoined by the law, out to cease." There 
appears no more need (or just about the same) for restrict- 
ing the liberty of lepers as for restricting the liberty of those 
afflicted with gout. 

Lichen. — Definition. — An eruption commencing as small 
red papulae, either isolated or confluent. These becoming 
excoriated, give vent to a serous fluid in considerable abund- 
ance, which ultimately concretes into a crust. 

Treatment — Glycerine in the following formula is recom- 
mended by Mr. Startin : 1^ • Aci d Nit. dil. 3 ss to 3 j j ; Bismuth 
sub. nit. 3 ss; Tinct. digital., 3j; Glycerini, § j* Aq. 
Rosse, f § vii ss. "To be applied as a lotion frequently' to 
the affected parts." 

The alkalies internally and externally are of service. Bi- 
carbonate of soda, in fifteen grain doses in some bitter infu- 
sion, to be increased by eight grains daily till 3 j is taken in 
the twenty-four hours (Divergie). Alkaline baths and lo- 
tions are to be used at the same time — the lotions containing 
two or three drachms of the salt to twenty ounces of water. 

lilYev, Abscess Of — Definition. — Suppurative inflamma- 
tion, ending in a circumscribed collection of pus, or in sev- 
eral separate abscesses. 

Treatment. — The abstraction of blood is most efficiently 
accomplished by leeches round the anus. They act more 
directly on the portal circulation than over the hepatic re- 
gion. When congestion is known to exist, leeches may be 
applied with benefit, combined with purgative salines, such 
as sulphate of soda or Rochelle salts, and antimony as a dia- 
phoretic, to be followed by chloride of ammonium. Hot fo- 
mentations applied to the region of the liver are of great 
service, and the diet should be as limited as is consistent 
simply with the maintenance of life, as long as acute symp- 
toms exist. Mercury should not be given, except as an oc- 
casional purgative, when the local inflammation is subdued, 
and purgatives are only then of use when the intestinal func- 
tions are sluggish. It is still a question whether or not an 
artificial opening ought to be made, in the absence of fluctu- 
ation to justify the operation. " In any cases the opening of a 
liver abscess is a critical proceeding; but it should be resorted 
to whenever there is a reasonable prospect of getting at the 
matter, and when operative proceedings are not so danger- 



240 LIVER, ABSCESS OF. 

ous as to be prohibitory, for it is very desirable to anticipate 
spontaneous opening by any of the usual channels, as all are 
dangerous. Into the peritoneum, pleura, or pericardium, the 
result is of necessity almost always fatal; while even into 
the lung, stomach, or bowel, the danger is often great; and 
though followed by temporary amelioration, may end in 
exhausting disease or purulent contamination of the whole 
system" (Sir Joseph Fayrer). Professor Lister's antisep- 
tic method of procedure appears to me the one which 
ought to be adopted in opening all hepatic abscesses. 

" When there is reason to believe that matter has formed, 
although the physical signs of it may not be clear, attention 
should be directed carefully to the evacuations, especially if 
there be diarrhoea, as the abscess may open into the bowel. 
This is the probable explanation of recovery in cases where 
it has been thought that the abscess had either never really 
formed, or that it had undergone absorption. When opening 
occurs through the lung or stomach, the symptoms are un- 
mistakable. When abscess has formed, the object is to favor 
its evacuation, to support the strength, and to allay irritation. 
Much has been written and said about exploring for liver 
abscess, and in certain cases, where doubt exists, the pro- 
ceeding is justifiable, using a small canula and aspirator, 
when there is enlargement, tenderness on pressure, which 
causes nausea and disturbance of the heart's action, such as 
palpitation or sickness, especially if there have been any chills, 
increase of temperature, or sweats. — In the event of matter 
being detected at a considerable depth, it may in some cases 
be aspirated ; but it may happen that, on account of its 
thickness and the presence of flakes of lymph, pus will not 
pass through the small canula, and no satisfactory result is 
obtained ; but if there be any marked probability of its 
presence, a large canula may be used and left in after if pus 
is found, the most careful antiseptic precautions being ob- 
served in the subsequent dressings. Whenever the matter 
lies moderately near the surface, even though a certain 
amount of liver- tissue intervene, a free incision is best; 
hemorrhage, should it occur, soon ceases, and there is much 
better prospect of a free drain afterwards. A large canula 
may in some cases be preferable. It would signify little 
which were selected, provided antiseptic precautions be 
carefully observed, and the exit be free. In the event of 
exploration detecting matter deep-seated, but under much 
liver substance, the canula is preferable to the knife, used 



LIVER, ABSCESS OF. 241 

with the aspirator, though great care should be taken not to 
exhaust too rapidly, or with too great force, for fear of injur- 
ing the liver tissue surrounding the cavity of the abscess and 
causing hemorrhage." (Sir Joseph Fayrer, Lancet May 8, 
1880, p. 709). "Cases of doubtful liver-abscesses present 
symptoms varying in every degree ; at the one extreme cases 
of general cachexia, with irregular slight febrile attacks, 
exhibit symptoms as frequently attributable to deranged 
stomach, or bowels, or lungs only, as to the liver itself ; 
while at the other, slight general enlargement of the organ 
would be found associated with that peculiar form of ' ten- 
derness ' in which pressure over the organ produced an 
indescribable sensation, inducing either faintness, hurried 
respiration, palpitation, or nausea with retching, or all of 
these at once. In all this large class of cases it was the cus- 
tom of Professor W. S. Palmer, of Calcutta, to plunge a long 
trocar and canula, of small diameter, into any or all parts of 
the liver, through a valvular opening, examining on the spot 
the small quantity of extracted matter for pus globules. It 
was only in exceptional cases that any signs of pus could be 
detected. When it was so detected the puncture was gener- 
ally followed by slight inflammatory action at the seat of 
puncture, which probably ended in adhesion of the organ to 
the parietes, and so facilitated the future opening of the 
abscess. When, on the other hand, no pus was found, a 
good deal of anxiety was felt in the earlier cases, lest the 
puncture should be followed by any evil results. Such 
moments of anxiety soon ceased to recur, for it very rarely 
happened that the patient did not express himself the next 
day as feeling very much relieved ; and in no case did any 
bad consequences result from such punctures. The relief 
was frequently only temporary, in which case a second, a 
third, or a fourth puncture was made at intervals of eight or 
ten days. In some, however, one puncture sufficed to cure " 
(Lancet, May 8, 1880, p. 709). 

To prevent the entrance of pus into the abdominal cavity, 
the following method has been recommended by Begin and 
Recamier : (1.) Being decided as to the limits of the abscess, 
the patient is (2J laid on his back, with the upper part of the 
body bent forward, and the thighs flexed upon the abdomen; 
(3.) an incision from two to three inches long is to be made 
over the abscess, dividing the skin, the subcutaneous adipose 
tissue, the muscles, and the aponeurosis ; (4.) the pejitoneum 
is then laid open, as in operating for hernia, by slitting it up 
16 



242 LIVER, ABSCESS OF. 

on a grooved director to the same extent as the primary in- 
cision ; (5.) the wound is then to be dressed with charpie, 
and to remain untouched for three days ; (6.) at the end of 
three days the dressing is to be removed, when the capsule 
of the liver will be found to have contracted adhesions to the 
margins of the wound so firm that the abscess may be opened 
without the danger of pus passing into the abdomen. The 
following expedient may indicate whether the liver adheres 
to the abdominal parietes or not. When the liver is large, 
and the abdominal parietes are thin, it may be made out 
" by feeling the edge of the liver, or some prominent part of 
its surface, and marking the place of this with a pin on the 
surface of the belly. If the liver be adherent to the abdom- 
inal parietes, the line or spot so marked will correspond to 
the edge or prominence of the liver in all positions of the 
body. If it be not adherent, the liver will slide along the 
wall of the belly when the patient draws a deep breath, or 
changes his posture — the liver will fall, for example, towards 
the left side when he turns from his back over to that side, 
and the line or spot will no longer correspond to the edge 
or prominence in question (Budd, op. cit., p. 122). 

An interesting case of hepatic abscess is related by Sir 
Henry Cooper, of Hull, in the British Medical Jotirfial for 
May 23, 1863. He justly takes exception to the method of 
Begin and Recamier, because it may provoke the very danger 
it is desirable to avoid. In all cases in which suppuration 
has extended so near the surface as to give the sense of fluc- 
tuation, irritation and adhesion of contiguous surfaces have 
taken place. The process also interposes a serious delay at 
a critical period. He advocates a direct opening into the 
abscess, when there is reasonable ground for believing that 
an external outlet for the matter is the direction taken by 
the abscess. Peritoneal connections are sure then to have 
taken place. Tenderness of the tumor is the most satisfac- 
tory indication for the operation, and hardened base of 
effused lymph a certain confirmation. Delay exposes the 
patient to the risk of rupture of the walls of the abscess by 
coughing, sneezing, or the like, and to the laceration of any 
adhesions which may have formed ; or it allows him to 
perish unrelieved from constitutional irritation and conse- 
quent exhaustion. A middle course was devised and carried 
out by Dr. Graves, in the Meath Hospital, in a robust man. 
External elevation, hardness, and pain, eventually confined 
to one spot in the right hypochondrium (after acute inflam- 



LIVER, ABSCESS OF. 243 

mation of the liver), left to doubt of the formation 
of an abscess. Hardness was followed by deep-seated 
softness, yet no tendency was shown by the abscess to 
point outwards. The swelling remained stationary, and the 
integument of natural color ; but the general strength 
began to fail, and it became an important question 
whether the abscess should be opened. It was objected — 
(1.) That the external tumor was diffuse ; (2.) that the exact 
site of the abscess was uncertain; (3.) that failure to evacu- 
ate its contents might prove detrimental. A decision was 
therefore given against operation by the surgeons of the 
Meath Hospital. Under these circumstances Dr. Graves 
remembered that he had seen cases where an incision made 
over a deep-seated abscess had failed to give vent to the 
matter in the first instance; yet in the course of a few days 
the pus found its way to the incision, and burst through it. 
He therefore proposed that an incision about four inches 
long should be made exactly over the center of the tumor — 
that it should be carried through a considerable depth of 
muscle, and, if possible, be continued to within about one or 
two lines of the peritoneum. This incision was then to be 
plugged up from the bottom of the wound with lint, and 
thus kept open, in the hope that pus might tend towards the 
incision, and finally burst through it. Such an operation 
was done. The abdominal muscles were found of consider- 
able thickness, and healthy; and although the incision was 
very deep, yet the situation of the hepatic abscess was not 
felt more distinctly. It now became evident that no pru- 
dent surgeon would have persevered in an attempt to open 
directly into it. A result was therefore waited for. In two 
days the patient sneezed, when purulent matter in very large 
quantity burst through the wound. It appeared that the in- 
cision had not been made exactly over the abscess, but 
rather to one side of it; for the matter did not come from 
the bottom, but from the side of the wound; and pressure 
on the liver on that side caused matter to flow out in abund- 
ance through that part of the wound which communicated 
laterally with the abscess. Had the original incision been 
continued, it might have failed to open into the abscess 
{Dublin Hosp. Report, Vol. IV., p. 40). 

After the abscess has opened, strict rest must be enjoined; 
and sometimes the cavity is very long in closing up. It 
must be kept from putrefactive changes by antiseptic dress- 
ings. Convalescence is always tedious; and sometimes 



244 LIVER, ABSCESS OF. 

cicatrization is imperfect, continuing to discharge pus for 
years (Frerichs). It has been argued, as already indicated 
in the experience of Dr. Palmer of Calcutta, that our effort 
should be directed to detecting by acupunctuie the seat of 
an abscess, and evacuating it as soon as possible; and that 
this metho*d of exploration or of "prospecting the liver," 
should be commenced as soon as symptoms present them- 
selves indicating the possibility of abscess. It has been 
argued that because some cases have recovered after such 
a method of finding and evacuating an abscess, it is a prac- 
tice which should be made the rule, in place of waiting for 
some indications that pus has even formed in the liver (Mur- 
ray, Cameron). The recommendations to the plan are not 
yet based on statistical records, and rest upon the opinions 
or impressions of two or three individual men. Certain it 
is that the plan recommended is opposed to the well-estab- 
lished principles upon which surgical interference rests, and 
is opposed to all that is known regarding the pathology 
of hepatic abscess, as set forth in the carefully recorded 
facts of Waring, Martin, Morehead, Frerichs, Budd, Mac- 
lean and Lowe. It is also stated by Dr. Cameron (the latest 
exponent of this method of puncture), that in cases of hepa- 
tic enlargement, where the trocar has been used more than 
once in an unsuccessful search for an abscess, the operation 
was followed by the speedy absorption of an enlargement of 
the liver, which had resisted all the routine methods of 
bringing about its dispersion; and that chis is a native mode 
of dispersing hepatic and even splenic enlargements in India 
{Lancet, August 8, 1863, p. 169). Puncturing parts, or acu- 
puncture with a very fine needle, is a surgical operation said 
to be much in use among the native Chinese and Japanese 
hakims. But accurate information regarding the results of 
such operations are not on record. It should be remem- 
bered, in dealing with large livers or probable hepatic ab- 
scess, that an hepatic abscess always begins from multiple 
foci (Rokitansky). We must still look to physicians of large 
Indian experience for information on this important subject; 
while the antiseptic method of Lister warrants operative in- 
terference now which could not have been carried out with 
safety before. 

The time which elapses after opening an abscess till the 
patient's recovery is generally from one to two months. 
When convalescence is established, the functions of the 
liver remain torpid, and its substance often indurated; sub- 



LIVER, ACUTE ATROPHY OF. 245 

sequently, also, trie spleen may be enlarged. In such a 
state Sir Ranald Martin recommends the use of nitro-muri- 
atic acid baths. They promote the depurative functions of 
the liver, kidneys, bowels, and skin. 

" The form and manner of preparing and using the acid 
bath are as follows: — Take of hydrochloric acid, three 
parts; nitric acid, two parts; mix the two acids carefully 
and slowly, so as to avoid evolution of heat; and having 
waited for twenty minutes, add of distilled water five parts, 
and mix the whole carefully. For a general bath in which 
to immerse the whole body: — Pour into the bath about five 
pailfuls of cold water; add two quart bottles, containing 
sixty-four fluid ounces of the dilute nitro-muriatic acid, pre- 
pared as above, and then sufficient boiling water to raise 
the temperature to 96° or 98 . The body is to be quickly 
and thoroughly dried with warm towels; and afterwards the 
patient must retire to a well-aired and warm bed. The use 
of the bath is only to be discontinued when tenderness of 
the gums or general malaise occur; and cuticular irritation 
from the acid is to be avoided by diminishing its strength. 
Iron and other forms of tonic remedies may also be admin- 
istered at the same time, as well as opiates," (Martin, On 
Climate, p. 564, et scq). 

LiYer, Acute Atrophy of. — Definition. — Simple jaun- 
dice, which gradually increases, with sensitiveness over the 
region of the liver, followed by violent constitutional dis- 
turbance, expressed by pyrexia, headache, delirium, hemor- 
rhages from various parts, and finally coma. The liver 
shrinks to one-half or one-third its normal size. A peculiar 
chemical decomposition takes place in the liver, whereby ab- 
normal proximate principles are formed, which, being carried 
into the blood, may be discovered in various organs of the 
body, or, passing out by the kidneys, may be found in the 
urine. 

Treatment. — English physicians recommend emetics and 
purgatives (Corrigan, Griffin, Hanlon). Frerichs recom- 
mends that the stronger purgatives should be simply to re- 
move congestion, such as senna, aloes, colocynth ; and the 
doses should be such as to secure profuse evacuations. 
When atrophy has commenced, no benefit results from med- 
icinal treatment. Severe pains indicate the use of leeches, 
cupping, and cold cloths, or fomentations, as recommended 
under " Enteric Fever." The occurrence of haemorrhage 
indicates the use of mineral acids. 



24^ LIVER, AMYLOID LIVER, FATTY. 

Liver, Amyloid — See Liver, Lardaceous. 

Liver, Cirrhosis Of the. — Definition. — Interstitial in- 
flammation, with increase of the connective tissme and its 
subsequent contraction, leading to other alterations and re- 
sults. 

Treatment is the possibility of relieving the disorders of 
function which threaten life, and so to delay the fatal termin- 
ation. Absolute abstinence from spirits is indispensable, and 
the diet should consist of mild, simple articles of nourish- 
ment, especially easily digested animal food. Coffee, spices, 
and articles irritant to the liver must be avoided. Swelling 
and tenderness indicate leeches and fomentations. Mild 
saline laxatives may be given ; and when the tenderness 
ceases, the bowels must be kept open by rhubarb and salines. 
When nausea or vomiting occurs, hydrocyanic acid, belladon- 
na, morphia, or extract of mix vomica, are particularly suit- 
able. The gastric and intestinal catarrh require to be sub- 
dued by alkaline carbonates. They lessen the viscidity of 
the mucous secretion. When pain prevails, cupping or 
leeches are indicated over the liver, or leeches to the verge of 
the anus. Saline purgatives, such as sulphate of soda or tar- 
trate of potash and soda (Rochelle Salts), should also be ad- 
ministered, while iced drinks and low diet must be the rule 
of life. 

What has been said under the subject of simple enlarge- 
ment or congestion of the liver may be referred to here as 
indicating a line of treatment under the circumstances there 
provided for. The saline laxatives are best taken as mineral 
waters, especially at Karlsbad or Marienbad. Springs con- 
taining small quantities of iron are also of service, such as 
Eger, Franzensbrunnen, Kissengen, and Homburg (Nie- 
meyer). 

Liver, Congestion Of — See Liver, Simple Enlargement of 

Liver, Fatty. — Definition. — (1.) Infiltration or deposit 
of superfluous fat in the liver-cells, commencing at the cir- 
cumference of the lobules, from the blood of the portal vein 
capillaries ; (2.) Degeneration of the liver-cells, in which the 
nutritive process within the hepatic cells is disturbed, so that 
an abnormal increase of the fat naturally contained in the 
hepatic cells takes place, which remains there, so that they 
become engorged with oil. 

Treatment. — Dr. Murchison recommends that large quan- 
tities of common salt be eaten with the food, while, if the 



LIVER, LARDACEOUS LIVER, ENLARGEMENT OF. 247 

circumstances permit, the alkaline or saline mineral waters of 
Carlsbad, Marienbad, Kissengen, Ems, Vichy, Eger, Franz- 
ensbrunnen, or Homburg, are to be advised. The diet must 
be carefully prescribed, and regulated daily. 

Liver, LardaceOUS. — Definition.— -The existence of a 
peculiar homogeneous, translucent, albuminoid material in 
the hepatic arteries, cells, and texture of the liver, resembling 
an infiltration, but the albuminoid material is not found as 
such in the blood. 

Treatment. — It is desirable to limit the suppuration of 
bones as much as possible by early surgical interference. 
Iodine and iron are the remedies indicated by the nature of 
the disease and the circumstances under which it occurs ; 
but nothing is known as to the effects of remedies. 

Liyer, Inflammation of— See Hepatitis. 

Liver, Simple Enlargement of. — Definition. — Simple 
enlargement of the liver, from fulness or distention of its 
blood-vessels and bile-ducts. 

Treatment. — A restricted and judicious diet is of first im- 
portance, with abstinence from rich dishes and fermented 
liquors. With regard to medicine, Plummer's pill at bedtime, 
followed by Rochelle salts in a seidlitz powder, or Pullna 
water, in the morning, or by the usual black draught, or 
compound mixture of senna, or by such saline purgatives as 
sulphate of soda and bitartrate of potash (which cause a 
drain from the portal system of veins), usually give relief. A 
purgative dose of calomel, especially combined with com- 
pound jalap powder, is of all combinations the most efficient 
in diminishing congestion of the liver. After its action the 
local weight, the pain, the fulness, and other symptoms sub- 
side concurrently, with copious bilious stools. In such cases 
it seems to act by irritating the upper part of the small in- 
testine, propelling onwards the bile as fast as it flows into 
the duodenum, thus preventing its reabsorption (Murchison). 
The bilious accumulations thus evacuated constitute the 
"bilious stools ; " but they are not to be regarded as the re- 
sult of increased biliary secretion from the liver itself. An 
active aperient ought to be prescribed every second or third 
day for ten days or a fortnight after the action of the calo- 
mel and jalap purgation (Graves). In chronic congestion the 
external use of iodine ointment sufficiently diluted is of ser- 
vice. Dr. Graves bears testimony to the value of setons over 
the hepatic region. Two leeches every second day to the 



248 LIVER. SIMPLE ENLARGEMENT OF. 

verge of the anus, and repeated from ten to fifteen times, 
yield excellent results. Nitro-muriatic acid is a valuable 
remedial agent. Podophyllin, in small repeated doses, best 
relieves the engorgement and torpor of the liver in those who 
have resided long in tropical climates (Gairdner). It may 
not act for ten, twelve, or even twenty hours, when the purg- 
ing which results is due to the large amount of bile passed 
into the bowels. It stimulates the liver to increased secre- 
tion. The best mode of administration is to dissolve podo- 
phyllin in spirits of wine, in the proportion of one grain to 
the ounce, and combine it with essence of ginger, in the pro- 
portion of 3 iss. to the ounce. A teaspoonful of this mix- 
ture in a wine-glass of water every night, or every second or 
third night, secures all the advantages of podophyllin with- 
out the disadvantages which result when given in pills (Do- 
bell, Brit. Med. Journ., May 24, 1879). Chloride of am- 
monium is especially indicated when congestion is the prom- 
inent condition. It should be given in doses of grs. v. to xx. 
twice or thrice a day after food, combined either with acids 
or alkalies, according to the special indications of the case. 
The skin must be first induced to become moist and perspir- 
able by some diaphoretic. If it is hot and dry, with a tem- 
perature of 103 or 104 Fahr., a sixteenth of a grain of tar- 
tar emetic should be given every three or four hours till dia- 
phoresis occurs (Dr. Wm. Stewart, Philadelphia Med. Times, 
April, 1878, also under Hepatitis). When colored deposits 
are present in the skin, chlorate of potass should be com- 
bined with the chloride of ammonium. Benzoate of soda is 
another hepatic stimulant of value (Dr. Dobell). Taraxicum 
diminishes abdominal plethora : — 

Ext. Tarax., gr. xxxvi.; Ext. Aloes, gr. xii. ; Ext. Acet. 
Colchici ; Pulv. Ipecac, rad. aa., gr. vi. ; misce. Divide in 
pil. xii. Two pills every night. 

An electuary, composed of equal parts of sublimed sulphur 
and the powdered gum-resin of guaiacum, will be found use- 
ful in cases where the congestion of the liver is associated 
with haemorrhoids. When dropsy prevails, doses of the diu- 
retic pill of hydrargyrum, squills, and digitalis (a grain and 
a half of each ingredient), taken night and morning, are at- 
tended with benefit. In bilious congestion copious draughts 
of hot water act as an emetic, diluting the bile, and if some 
saline purgative be added, the congestion of the liver will be 
relieved. If pain prevails over the liver, leeches and fomen- 
tations are indicated, with perfect rest in the recumbent posi- 



LIVER, WAXY LOCOMOTOR ATAXY. 249 

tion — the diet consisting of arrow-root, sago, milk and water, 
barley-water, and afterwards beef-tea when convalescent. 

Lively Waxy — See Liver, Lardaceous. 

Locomotor Ataxy, Progressive. — Definition. — A pe- 
culiar disease of the spinal cord, characterized by unsteady 
and disorderly muscular movements (but with muscular 
power entire), and more or less progressive loss of the faculty 
of co-ordinating power (voluntary and instinctive). There 
is sometimes temporary diplopia, with unequal contraction 
of the pupils. The course of the disease is slowly progres- 
sive ; and the anatomical lesion is generally a (chronic my- 
elitis in the form of) ribbon-like sclerosis of the white pos- 
terior columns and horns of the spinal cord, and posterior 
roots of the spinal nerves, leading to grey degeneration, some- 
times with peripheral structure-change in the cranial nerves, 
and chiefly the second, third, and sixth pairs, in cases where 
the sight is affected. The disease generally begins in the 
lumbar region, and may extend throughout the entire cord, 
as far as the upper cervical portion, and even into the me- 
dulla oblongata. 

Treat7nent. — No benefit is to be got from antiphlogistic 
treatment, unless there be marked evidences of inflammatory 
irritation. Dry cupping may be of use for the relief of pain. 
Derivatives are likewise useless. Thermal baths are also in- 
jurious. Cool sponging of the body is of great use ; and 
cold-water treatment generally, especially the use of the cold 
sponge-bath (Erb). 

Phosphorus, in the form of phosphates of metals and salts, 
of diluted phosphoric acid, as a drink in the daily allowance 
of water, of phosphate of soda as an aperient, may be given 
with benefit. Strychnine is objectionable. Nitro-muriatic 
acid as a tonic, and cod-liver oil as a dietetic agent, may also 
be of use. Cannabis Indica and belladonna give the great- 
est relief to the pains. Nitrate of silver is recommended by 
Wunderlich, in doses gradually increasing to half a grain 
daily. Phosphuret of iron is also recommended. Dr. Al- 
thaus recommends sulphur baths as adjuvants, relieving pains 
and diminishing numbness. 

Flannel should be worn next the skin, and chills from cold 
and damp carefully avoided, by the use of a chamois leather 
or spun silk close-fitting jacket over the flannel, and reaching 
from the height of the clavicles as low as the folds of the 
nates behind. The diet ought to be of the most nutritious 
materials which the patient can digest. 



250 LUNGS, CONGESTION OF. 

So long as there is active local hyperaemia, the use of elec- 
tricity is hurtful. Faradization may be of use in restoring, 
to some extent, sensibility to the skin, where local cutaneous 
anaesthesia has prevailed, after which patients seem to walk 
better for a time; but when used at all, electricity ought 
only to be employed during the pauses in the course of the 
disease, and then with great caution, in the form of a con- 
stant current, rather than the induced current, or faradiza- 
tion. The current should be very weak at first, and the 
daily application for not longer than from three to six min- 
utes, extended over months. Niemeyer has had no suc- 
cess either with nitrate of silver or the constant current of 
electricity; but he recommends them to be tried. 

Lungs, Congestion of. — Definition, — An hyperaemia or 
over-fulness of blood in the capillaries of the lung, resulting 
in the discharge of blood by expectoration (haemoptysis); or 
in an extravasation of blood from capillary rupture into the 
air-cells, terminal bronchi and the interstices of elastic tissue 
(pulmonary apoplexy). 

Treatment. — The medicines most useful in haemoptysis are, 
the bitartrate of potash, in doses of a drachm, repeated every 
four or six hours, to each dose of which may be added a 
quarter to half a grain of opium. The mineral acids, as 
the infusion of roses, with diluted sulphuric acid, in doses of 
from three to five drops, combined with opium or morphia, 
every four or six hours. One to three grain doses of the 
acetate of lead, every four or six hours, may be given, with 
half a grain of opium to each dose, or combined with dilute 
acetic acid and laudanum (A. T. Thompson). The muriate 
of soda, in doses of half a drachm to a drachm, is in estima- 
tion with some practitioners on the continent. 

In atonic haemoptysis, ergot is said to be of service, espe- 
cially in the following combination: 

3- Ext. Ergotae Liq., 3 ii- ; Tinct. Digitalis, 3 ii- ; Acidi 
Gallici, 3i-; Magnes. Sulph., 3vi.; Acid. Sulph. Dil., 3i.; 
Infus. Rosae Acid., ad § viii. ; misce. A sixth part of this 
mixture to be taken every three hours, till haemorrhage 
ceases (Dobell, Warrmg-Curran). Wunderlich also recom- 
mends the secale cornutum, in doses of from five to ten 
grains, to be pushed until a numb sensation is experi- 
enced in the fingers and toes. 

The hypodermic injection of ergotine is by far the most 
efficacious of styptics in haemoptysis. A grain of (Bon- 



LUNGS, CONGESTION OF. 25 I 

jean's) ergotine should be injected on the back of the 
side of the thorax whence the bleeding comes, and re- 
peated every two or four hours ; and fifteen minims of 
tincture of digitalis should be given every three or four 
hours, its effect on the pulse being watched (Coghill). 

When haemoptysis is connected with amenorrhea, prepara- 
tions of iron often succeed when other remedies have failed. 
Two grains of the sulphate of iron, with one drachm doses 
of the sulphate of magnesia, three times a day, often restore 
the menstrual secretion, and cure the haemoptysis. It is in 
this form of amenorrhoea that iron is most successful. When 
haemoptysis depends on disease of the heart, cupping from 
the chest, or moderate bleeding from the arm, combined 
with the use of the bitartrate^of potash, or the mineral acids, 
to which should be added five to ten mimins of the tincture 
of digitalis, to give steadiness to the irregular, turbulent, or 
rolling action of the heart. Repeated dry-cupping, aided by 
the application of ice down the spine, and by the internal 
administration of full doses of digitalis — half a drachm of 
the tincture, or a grain and a half of the powder (Fuller). 
It is chiefly as an adjunct to other means, when haemoptysis 
is attended with much vascular excitement, that digitalis is 
of service. Full and frequent doses of gallic acid, or lead 
and opium, may be given, if the circulation is much acceler- 
ated; and of spirits of turpentine, in half-drachm doses, if 
the bleeding is unattended with vascular excitement. The 
gallic acid is more adapted for chronic cases, and should be 
given every hour, in eight or ten grain doses, until the 
haemorrhage is subdued, or till a dark-green color in the 
sputa indicates its action on the system. Its efficacy ap- 
pears to be increased by combination with sulphuric acid, 
and may be conjoined with opium or digitalis. 

The following formula is a useful one: — 

1> Acid. Gallic, gr. xxx.; Acid. Sulph. Dil., 3i.; Liquor 
Opii Sedat., m xxx. ; Infus. Rosae Co., f § vi.; misce. Two 
tablespoonfuls for a dose every three or four hours (Dr. L. 
Earle). 

Absolute bodily and mental rest must be insisted on 
throughout, in cases of pulmonary infarction. Stimulation 
must be resorted to in the first instance ; after which the 
mineral acids, or super-acid salts, appear to offer the best 
hopes of recovery. If the apoplexy be secondary, and de- 
pends on disease of the heart, digitalis may tranquillize its 
excitement. 



252 EMPHYSEMA LUNG, GANGRENE OF. 

Dietetic and Ge?ieral Treatment. — -The patient should be 
placed in bed, with his head and shoulders raised; the win- 
dow should be partly open, so as to keep the room cool. It 
has been recommended that the air respired should pass 
through a respirator containing ice; and it is common to 
place a bowl of ice immediately before the patient, so that 
he may suck small portions as often as he can. A large pad 
of spongiopiline, soaked in chloroform, should be laid on the 
chest, over the locality of bleeding. The bedclothes should 
be light but sufficiently warm. The diet should be slops, 
and these slops cold; and if cooled to a low temperature by 
ice, so much the better. No red meat, nor beef-tea or stimu- 
lants, are to be given; but milk, chicken broth, jelly, and 
iced lemonade. 

Emphysema. — Definition. — (1) Vesicular Emphysema 
Relative increase of air in few or many air-cells of the lungs, 
causing a misshapen enlargement of them, by dilatation or 
rupture of septa, and the blending of several into one or 
many great cysts. It is attended with gradual effacement 
of the functional blood-vessels distributed over their walls, 
anaemia of the lung in the affected parts, tending to dilata- 
tion of the right side of the heart, with anasarca. (2) In- 
terlobular Emphysema. — Air infiltrating the meshes of 
the sub-pleural and interstitial connective tissue of the lungs. 

Treatment. — Apart from the management of the bronchial 
congestion,, on the principles already given under Bronchitis, 
little can be done for the special treatment of emphysema! 
If bronchial spasm prevail, the spiritus astheris of the British 
Pharmacopoeia may give relief, of which thirty to sixty 
minims may be prescribed in camphor water, or in spiritus 
ammonias aromaticus, or in volatile tincture of valerian; or 
it may be conbined with stimulant doses (one grain) of 
opium; or with twenty minims of the aethereal tincture of 
lobelia, belladonna, conium; or the sethereal tincture of In- 
dian hemp and hydrocyanic acid may each in turn be found 
of service (Fuller). Dry-cupping between the shoulders 
'often relieves passive pulmonary congestion; and if an at- 
tack is imminent, an emetic, or unloading the bowels by a 
dose of the compound jalap powder, may prevent its acces- 
sion or moderate the paroxysm. 

Lung, Gangrene Of. — Defi?iition. — Disintegration and 
breaking up of the tissue of the lung. Shreds of lung-tissue 
may here and there be distinguished; but the whole mass be- 



LUPUS. 253 

comes converted into a heap of amorphous granular matter, 
of a yellowish-brown or black color, mingled with drops of oil. 
The tissue becomes soft and flaccid, in some parts perfectly- 
liquescent, and generally emits a fetid smell. 

Treatment. — The chief reliance is to be placed in all forms 
of stimulants, combined with such tonics as bark or quinine 
in full and repeated doses. Repeated doses of an ounce of 
yeast, as well as the influence of chlorate of potass, are sug- 
gested by Dr. Walshe. Ammonia has not been found so 
useful as the mineral acids. Inhalation of the vapor of tur- 
pentine, poured upon boiling water, exercises a distinctly 
remedial power (Skoda). Gargles of Condy's fluid should 
be freely used, and antiseptic inhalation, as described under 
" Phthisis." The mineral acids, especially nitro-muriatic, 
combined with quinine, are the main remedies in the chronic 
state of this disease. A generous diet, easily digestible, with 
as much malt liquor as can be taken, are also recommended. 

LlipilS. — Definition. — A spreading inflammation of the 
skin or mucous membrane, usually of the face, characterized 
by infective cell-growth, tending to destructive ulceration, 
but only by accident involving textures deeper than the skin. 

Treatment. — The new formation must be removed or de- 
stroyed; but opinions differ as to how this is best effected. 
Mr. Jonathan Hutchinson prefers Volkmann's erasion 
method. Cazenave recommends chloride of zinc, arsenical 
paste, or the powder of " Come," Vienna paste (equal parts 
of chalk and quicklime), and other powerful applications of 
the like kind. Hebra also recommends cauterization and 
employs usually strong nitric acid over the unulcerated, and 
nitrate of silver over the ulcerated surface. It is a remark- 
able fact in the history of lupus, affirmed by Hebra, that the 
lupus disappears during acute febrile diseases, and especially 
during typhus. It seems to recur with convalescence. (See 
Dr. A. Thomson on Diseases of the Skin, edited by Dr. 
Parkes, where numerous interesting cases are detailed, p. 

3 10 -) . . . 

The medical treatment has in view the prevention of the 

formation of more similar deposits in the substance of the 
skin by improving the general health. Cod-liver oil, phos- 
phorus, quinine, and bitter vegetable tonics, good food, 
bracing air, and the judicious use of stimulants, are all use- 
ful in this respect. Iodides and preparations of mercury are 
to be avoided; but arsenic may be given with advantage 
(Hutchinson). On the other hand, Dr. M'Call Anderson 



254 LUPUS. 

recommends the use of iodide of starch. [The following is 
the formula for its preparation: I£ Iodi, gr. xxiv; amyli, J j. 
Triturate the iodine with a little water, gradually adding the 
starch and continuing the trituration till the compound as- 
sumes an uniform blue color, so deep as to approach black. 
The iodide should be dried with a heat so gentle as to run 
no risk of driving off the iodine, and it ought to be kept in 
a well-stoppered bottle. On no account should spirit be 
used in its preparation instead of water. The dose is a 
heaped-up teaspoonful in a draught of water or water-gruel 
thrice daily; but it may be safely increased even up to an 
ounce in some cases]. In using it, care must be taken, first, 
that the cases are really undoubted cases of lupus erythema- 
todes and not lupus vulgaris; and second, that the medicine 
is freshly prepared, and in accordance with the directions 
above mentioned. Dr. Balmanno Squire has devised an im- 
provement upon the treatment of lupus by pricking the skin 
at short distances with a pointed instrument, as long since 
advocated by Dubini, of Milan, and subsequently by Volk- 
mann, of Halle. By means of a many-bladed instrument 
which Dr. Balmanno Squire has contrived, and which has 
been constructed by Messrs. Weiss, of London, he cuts the 
skin into thin strips. The Dubini-Volkmann method 
(known as punctiform scarification) has been highly success- 
ful. Dr. Squire's method (termed multiple linear scarifica- 
tion) has proved still more successful. It has been tested 
and commended in this country by Dr. Walter Smith, of 
Dublin, and Mr. Malcolm Morris, of London; while in 
Paris, at the Hopital St. Louis, Dr. Vidal and his assistants 
treat every Wednesday as many as from forty to fifty patients 
by this method. The advantages are the same as those 
which attend punctiform scarification — namely, the setting 
up of a traumatic inflammation, under which the disease 
heals; but the superiority claimed for treatment by closely 
and regularly spaced incisions is a more rapid and at the 
same time a more complete cure of the disease than can be 
effected by means of irregularly distributed punctures. Dr. 
Vidal had observed, in sections of the skin thus healed, the 
gradual conversion of the lupus cells into fibrous tissue. The 
advantages of treatment of the disease by the excitement of 
traumatic inflammation as compared with other means of 
treatment, are described as being less painful, as causing less 
loss of substance, and as leaving less permanent trace of its 
performance than the customary methods of local treatment, 



MEASLES. 255 

namely, the application of caustics or semi-caustics {Brit. 
Med. Joum., August 23, 1879, p. 293). 

Malignant Purpuric Fever — See Cerebro- Spinal Men- 
ingitis. 

Measles. — Definition. — A purely contagious and infectious 
disease, the virus or contagium passing off in the exhalations 
of a patient, causing the surrounding air to be contaminated. 
The disease is capable of inoculation by the blood and secre- 
tions. An eruption occurs in crops of a crimson rash, con- 
sisting of slightly elevated minute dots, about the size of 
millet-seeds, and having a small papular centre, scarcely per- 
ceptible to the touch, and without any sensation of hardness. 
Several of these may unite in irregular circular forms, or 
crescents, or they may be isolated. The eruption appears on 
the thirteenth or fourteenth day after exposure to infection 
(Panum, Archiv. Gen. de Med., April, 185 1, p. 451, and Ed. 
Med. Journal June, 1858, p. 589, quoted by Murchison). It 
is preceded by catarrhal symptoms affecting the conjunctiva 
and air passages for about four days, accompanied with fever, 
which commences with repeated rigors — i. e., the real incu- 
bation period is about ten days. It lasts six or seven days, 
and the whole duration of the disease is completed in from 
nine to twelve days. Measles affects the system only once ; 
and sometimes prevails as an epidemic. 

Treatment. — The constitution during measles is little im- 
paired by the short continuance of the fever. The rule, there- 
fore, is to interfere as little as possible as long as the disease 
is pursuing its normal course, and merely to moderate and 
subdue symptoms when they threaten danger, knowing that 
the great majority of cases end in recovery without any medi- 
cal treatment. The morbilli sine catarrho is usually of such 
a mild form as to require no other treatment than a milk diet, 
the customary attention to the bowels, and the prevention of 
exposure to cold and wet. Measles will not bear exposure of 
the surface of the body to cold so well as either scarlatina or 
small-pox, on account of the great tendency to bronchial and 
pulmonary inflammation. Children must therefore be 
watched night and day to prevent them lying uncovered, and 
special care must be taken to avoid exposure to cold during 
convalescence. An even and moderately moist temperature 
must be maintained in the room, steam from a boiling kettle 
of water being admitted. The temperature ought to be regu- 
lated by the thermometer, and kept at 6o° to 65 ° Fahr. The 



256 . MEASLES. 

room must also be regularly subjected to a current of fresh 
air daily, the patient being sufficiently protected at the time. 
In the morbilli mitiores the cough, the frequent vomiting, 
and the. heavy catarrhal symptoms which so generally attend 
the primary fever, render medical attendance necessary from 
the first moment of the attack. The treatment of these 
symptoms, however, and also of the eruptive stage, as long as 
the patient continues free from any serious inflammatory af- 
fection of the lungs, need not necessarily be active, it being 
sufficient to alleviate the cough, allay the vomiting, and check 
the catarrh by some of the large class of saline laxatives, lin- 
seed tea, or mucilaginous mixtures, to which antimonial or 
ipecacuanha wine may be added, if necessary, as a diapho- 
retic, and to subdue high vascular action. In making a se- 
lection from these, the physician must be principally guided 
by the state of the bowels and the condition of the stomach 
of the patient. If the bowels be constipated, the milder 
salines, as the sulphate of magnesia, are to be preferred. 
Often, however, a diet of stewed prunes or fruit will be suffi- 
cient. On the contrary, if the patient be purged, and the 
vomiting distressing, a neutral mixture or effervescing 
draught will be found most beneficial. There are many per- 
sons in whom the cough and catarrh are the most urgent 
symptoms ; and in such cases, if the stomach be quiet, the 
liquor ammoniae acetatis, combined with camphor mixture, 
from its more powerful action on the skin, is an excellent ad- 
dition. Another remedy, equal or perhaps still more useful, 
is ipecacuanha wine. Willan was of opinion that an emetic, 
given on the second or third evening, somewhat alleviated the 
violence of the catarrhal symptoms, and contributed to pre- 
vent the diarrhoea which usually succeeds measles. An 
emetic is especially useful if the disease be threatened with 
croup as a complication. During the eruption he adds, " I 
have not observed any considerable effect from antimonials 
or other diaphoretics." The use of aconite has been found 
to moisten the skin ; and certainly helps the emergence and 
development of the eruption when due, though it seldom re- 
duces the temperature before the eruption comes out, but it 
reduces the pulse (Phillips). Bathing the feet every evening 
seems a beneficial application. Emulsions and mucilages af- 
ford but a feeble palliation of the cough and difficulty of 
breathing ; but if there is much oppression, with a sense of 
tightness, linseed poultice jackets must be applied to the 
chest. With respect to opiates, they are not advisable should 






MEASLES. 257 

bronchitis be extensive, and in the early stages especially ; 
opium produces an increase of heat and restlessness, without 
conciliating sleep. The catarrhal symptoms are frequently 
accompanied, even in the very earliest days of the disease, 
with much bronchial inflammation, and sometimes with pneu- 
monia ; or these affections may occur at an} 7- later period, 
after the decline of the eruption, from the tenth to the twelfth 
day of the attack. For these a stimulant treatment is re- 
quired. If pleurisy alone supervenes, mercury is best used 
in the form of friction with blue ointment over the chest, a 
little croton oil being added to promote its absorption (An- 
drew Anderson). In such cases stimulants are called for — 
e. g. subacetate of ammonia, chloric ether, wine, or brandy. 
During the whole course of measles it is necessary to enjoin 
an abstinence from animal food, and to limit the patient to a 
low diet and to slops. Liquid food should be given in small 
quantities at frequent intervals. The chamber should not 
be subject to any sudden change from heat to cold, and the 
strictest cleanliness should be observed. With a view to 
protect the eyes, the room should be kept dark, so that the 
patient maybe prevented reading or using his eyes. In large 
establishments separation is necessary, to prevent spreading 
of the disease, if possible. Should the eruption disappear 
(" striking in of the eruption "), or be retarded, and untoward 
symptoms appear, it is just as unscientific as it is dangerous 
to attempt its "restoration." It is dangerous, because the 
rules usually laid down for this emergency may have an inju- 
rious effect on the course of the disease. The disappearance 
of the eruption is not to be regarded as the cause, but as the 
result of a bad form of the disease, and due to the general 
collapse of the patient, in which the skin participates. But 
this bad form of the disease usually depends on the appear- 
ance of some complication, especially pneumonia ; and, if 
this fact be not remembered, and the patient be rubbed with 
irritating applications, or be placed in a hot bath, with or 
without mustard, or wrapped up in wet blankets with decoc- 
tion of mustard, " to bring the eruption out again," we shall 
often do much harm, even if we succeed in our object, because 
these procedures do not generally act advantageously on the 
pneumonia and other complications, while they increase the 
fever " (Niemeyer, Text-book of Practical Medicine). When 
convulsions occur in children, it is in all cases necessary, in 
the first instance, to determine the most probable source of 
the irritation giving rise to the convulsions — /. <?., whether 
17 



258 MEASLES, GERMAN— MENINGITIS. 

they depend upon the specific poison of the disease, upon 
dentition, or upon intestinal irritation or cerebral disorder. 
Hot foot-baths sometimes give relief, as well as sinapisms to 
the limbs ; after which, if the convulsions do not subside, 
it may be necessary that blood be taken by leeches from the 
temples. Diarrhoea should not be checked suddenly, but 
kept under control. The patient ought to remain in bed so 
long as fever is present, while desquamation is going on, and 
the cough is severe ; and he ought to keep his room so long 
as catarrh is present. A low state of the general health may 
finally result, requiring quinine, iron, or cod-liver oil ; change 
of air — especially to the sea-side — and sea-bathing, or cold 
bathing in salt water. 

Measles, German — Rotheln. — Definition.. — A specific 
eruptive disease, having an incubation period of ten to 
fourteen days (Squire), or from two to three weeks (Thomas), 
followed by fever, watery discharge from the eyes and nose, 
sneezing, and sore throat. The eruption appears on the 
third or fourth day, and consists of crimson stigmata, rapidly 
running together into patches of an irregular shape, with 
obtuse angles, and of sizes varying from a threepenny to a 
crown piece, according to the severity of the case. The 
eruption continues from six to ten days, and terminates in 
desquamation by furfuraceous scales. 

Treatment. — The treatment is similar to that of scarlet 
fever. The functions of the skin are ff possible to be stim- 
ulated ; and Dr. Paterson found that the aqua acetatis 
ammoniae, in the proportion of two ounces to half an ounce 
of antimonial wine, and four ounces of water, was a most 
useful remedy. The use of colchicum was also had recourse 
to with decided benefit. 

Meniere's Disease. — (See Vertigo, auditory). 

Meningitis, Cerebral and Spinal. — Definition. — In- 
flammation of the immediate coverings of the brain and 
spinal cord, the pia mater, and arachnoid (pia-arachnitis). 

Treatment. — As a general principle, remedies have little 
influence over those forms of the disease which arise during 
the progress of any specific or constitutional disease, inde- 
pendent of the general treatment indicated for that disease. 
When pia-arachnitis arises from mechanical injuries, the 
treatment is generally by bleeding. If the first symptoms 
are characteristic of inflammation of the meninges of the 
brain, and we can only conjecture what it may turn out, 



MENINGITIS, CEREBRAL AND SPINAL. 259 

leeches behind the ears ought to be applied in the first in- 
stance. If this local abstraction of blood proves beneficial, 
it may be repeated during subsequent relapses. At the out- 
set of the disease laxatives and ice compresses may also be 
used (Niemeyer). Th'ere is, perhaps, no class of cases in 
which the sanative powers of judicious blood-letting become 
so apparent as in children in whom the disease has been 
observed early and carefully watched. When the inflamma- 
tory symptoms are less decided, and the headache slight, 
and the disease drags on slowly, a single venesection is ad- 
missible. [Dr. Alison relates the following highly illustra- 
tive case, confirmed now by the teaching of Niemeyer : — • 
" A boy, aged eight years, of rather delicate habit, and who 
had complained occasionally for some weeks of headache 
and disordered bowels, temporarily relieved by laxatives, 
calomel, antacids, and a careful regimen, but recurring, and 
attended with gradually increasing febrile symptoms, and 
shooting pain of head ; impatience both of light and sound ; 
pulse gradually rising to 108, distinctly sharp, and beginning 
to intermit ; and then nausea and vomiting, not referable to 
any medicine taken, but gradually increasing, until it re- 
curred every time that he sat up in bed, for nearly twenty- 
four hours ; and a slight but quite perceptible squint show- 
ing itself. The full action of laxatives and one application 
of leeches, as well as cold to the head, having failed to make 
any impression on this course of things, he was bled at the 
arm (which in such circumstances and at that age has often 
appeared to me distinctly preferable) to twelve ounces, and 
the blood was sizy. I do not know what further evidence 
we could have had of the existence of such inflammation 
within the cranium as would infallibly, if let alone, have gone 
on within a few days to delirium, stupor, dilated pupil, slow 
pulse, succeeded by very frequent pulse, convulsions, and 
death, and have left after it the usual appearances of the 
acute hydrocephalus (of Whytt, Cullen and Abercrombie, 
now described), dryness of the membranes on the surface of 
the brain, distension of the ventricles of the brain with 
serum, and some of the marks of inflammatory action either 
on the membranes or surface of the brain. Instead of this, 
however, I am quite certain that from the time of the bleed- 
ing at the arm, this boy never once vomited, that the inter- 
mission of the pulse was never again observed, nor did he 
again complain of lights or sounds. The pain of the head, 
although less violent, continued in the evening of the same 



260 MENINGITIS, CEREBRAL AND SPINAL. 

day, and twelve leeches were applied within eight hours after 
the bleeding ; and from that time he never once complained 
of this symptom, nor admitted that he felt it ; and from this 
moment he recovered perfectly, and much more rapidly than 
he had done from much slighter febrile attacks previously ; 
neither has he suffered from that time to this (now thirty 
years) any return of serious disease" {.Edin. Med. Journal, 
p. 777, March, 1856.) In short, all the symptoms vanished 
in twenty-four hours, most of them during the flow of blood, 
and never recurred — a change, under the circumstances, so 
sudden and sanative as is rarely if ever seen after the 
use of any other remedy for the same combination of symp- 
toms.] 

With reference to the sanative influence of general blood- 
letting in children for inflammatory diseases, if performed at 
the outset, Dr. West observes, that such depletion is as im- 
portant a remedy as in the adult ; nor will the most energetic 
employment of any other antiphlogistic measure enable us to 
dispense with blood-letting. In a healthy child two years 
old, a vein (if easily found) may be opened in the arm, and 
four ounces of blood allowed to flow, if faintness be not 
earlier produced, without our having any reason to appre- 
hend that the plan adopted is too energetic. The immediate 
effect produced is greater than that which follows local de- 
pletion, and the quantity of blood abstracted is less (West, 
Diseases of Children). Bleeding in children and in adults 
exercises an influence quite different — because under totally 
different circumstances — not yet inquired into ; but certain- 
ly blood-letting at ages under adult life is soon repaired 
compared to its reparation after that period. Hasse recom- 
mends very small doses of morphia (J± of a grain) in the 
early stages. 

The first thing to be done by way of medicine is to purge 
the patient. The purgative is not of great moment, provided 
it acts freely. Some prefer two to five grains of gamboge, 
others five grains of calomel, with thirty grains of compound 
jalap powder. Such doses are to be followed up by a black 
draught, or the sulphate of magnesia. So difficult is it to ob- 
tain the action of purgatives in this disease, that doses of three 
times the strength for adults have been in some instances re- 
quired ; but such large doses are never to be given until 
the inefficiency of smaller ones has been ascertained (Sir 
Thomas Watson's Lectures, No. XXVI). The stools are 
generally black, or extremely offensive ; and, this state of the 



MENINGITIS, CEREBRAL AND SPINAL. 261 

bowels corrected, the disease, if sympathetic, often ceases. 
If, however, the head be not relieved, some leeches should 
be applied to the temples, and the head should be shaved 
and surrounded with some cold evaporating lotion, such as a 
towel dipped in cold spring water, or in vinegar and water, 
or in solution of the muriate of ammonia, with vinegar. 

In chronic cases, Foville strongly recommends the cold 
douche — pouring cold water over the head from a pitcher 
held some distance above it. This remedy must be used 
with caution, as it is a powerful depressant, yet producing less 
ultimate debility than bleeding. It acts, doubtless, by cool- 
ing down the general mass of the blood ; and patients almost 
always recover consciousness under its influence. To secure 
a lasting result it must be repeated at intervals of a few hours 

In children I have certainly seen good results from inunc- 
tion with mercurial ointment. (See remarks under the treat- 
ment of " Hydrocephalus.") In advanced life it rarely hap- 
pens that the symptoms are so intense as to demand general 
blood-letting ; but in vigorous constitutions this measure is 
sometimes necessary. The cases which demand it are those 
attended by high cerebral excitement and vascular action. 
But as a rule local blood-letting is not only infinitely more safe, 
but more beneficial, and it can be repeated from time to time, 
as the nature of the symptoms may indicate ; while general 
blood-letting can very rarely be resorted to more than once, 
and that only at the commencement of the attack. The 
beneficial effects of local blood-letting may be greatly aided 
by keeping the head well raised, and by the constant appli- 
cation of cold water to the scalp ; or the occasional use of 
bladders filled with crushed ice. The bowels should be 
opened as rapidly as possible, unless the patient is feeble, 
emaciated, or greatly exhausted. The most active and 
searching purge is obtained by calomel and jalap ; or four 
or five grains of the compound extract of colocynth should 
be given, combined with two or three grains of calomel, in 
cases uncomplicated with gout or Bright's disease, and fol- 
lowed in a few hours with a dose of salts and senna. A fair 
proportion of nutriment must be given, in the form of milk, 
strong beef-tea, sago, tapioca, or arrowroot ; 'and the patient 
should be kept in a quiet, cool, well-aired, and darkened 
room, and with cold compresses constantly applied to the 
head. The more active symptoms being subdued, but not 
till then, a blister should be placed on the nape of the neck. 
The bowels should be kept open regularly, and the strength 



262 MENINGITIS, CEREBRAL AND SPINAL. 

supported by mild, unstimulating nutriment. When nervous 
irritability continues during convalescence, henbane, or mu- 
riate of morphia may be given. In the chronic form the 
periodical attacks of headache or of insanity may generally 
be relieved by a brisk purge ; and the head should be kept 
cool by cloths dipped in vinegar and cold water. If vascular 
excitement prevails, leeches may be applied behind the ears. 
The bladder must be kept empty of urine by the catheter, 
and although wine must be withheld during the active stage of 
the disease, it is beneficial when the vital energies begin to 
fall (Maclachlan). 

The dietetic treatment should be strictly antiphlogistic, the 
patient especially avoiding all mental excitement ; and, if not 
secluded, he should at least be kept tranquil, not only in 
body, but also in mind. 

Spinal arachnitis, seldom depending on a morbid poison, 
is perhaps in all cases best treated by bleeding and mild 
purgatives. General bleeding is sometimes necessary ; but 
local bleeding, either by cupping or leeches, along the verte- 
bral column, is most useful, and cannot be omitted with 
safety. The medicinal treatment consists in moderate purg- 
ing by the neutral salts, as the sulphate of soda or the sul- 
phate of magnesia ; for, as these act on the bladder as well 
as on the bowels, they are probably the best remedies. But 
whatever purgative may be selected, it will be proper to com- 
bine it with the tincture of hyoscyamus, or other mild opiate, 
to procure the patient any relief from his sufferings. Ergot 
of rye (secale cornutum) has been very much used in France; 
and Dr. Meryon speaks favorably of its effects, combined 
with iodide of potassium, in a case which manifested no 
complication of spinal effusion {Medical Times and Gazette, 
Aug. 31, 1S63). The warm bath is an excellent adjuvant in 
the earlier stages of the disease ; whilst in the later stages 
blisters, setons, moxae, or the ointment of the tartrate of an- 
timony, are more beneficial, or at least are deserving of a 
trial. The paralyzing effusion may disappear during their 
use, combined with the action of diuretics. The external 
application of belladonna and chloroform will be found of 
essential service in diminishing the violent pain which ac- 
companies meningitis of the cord (Meryon). Cold, in the 
form of bladders filled with ice, applied along the spinal 
cord, may be of service where congestion prevails. Abstin- 
ence from all animal diet should be imperiously prescribed 
throughout the whole course of the disease. 



MENINGITIS, CEREBROSPINAL TUBERCULAR. 263 

Meningitis, CerebrO- Spinal— See Cerebro- Spinal Men- 
ingitis. 

Meningitis, Tubercular. — Definition.— An effusion of 
serous fluid between the membranes of the brain, or into its 
ventricles, associated with miliary tuberculosis of the men- 
inges or at the base. 

Treatment. — Tuberculous meningitis, in the form of acute 
hydrocephalus, can only be successfully combated in the 
first or earliest stage. 

If the disease be advanced, no efficient treatment has as 
yet been determined. The symptoms do not yield to the 
lancet like those of simple inflammation. Mercury has been 
used to a great extent, but with little success. In severe cases 
mercurial ointment has been rubbed on the back and thighs, 
even in very young children, to the extent of half a drachm 
to a drachm three or four times in the twenty-four hours. 
Calomel also has been rubbed on the gums to the extent of 
three or four grains every four or five hours. It has like- 
wise been given by the mouth in does of two g' ains every 
third or fourth hour. Mercury given in these large doses 
seldom produces salivation in children under three years of 
age. But the remedy is not successful, and more generally 
produces spinage-like stools, and irritates the alimentary 
canal. 

On the other hand, Professor Golis of Vienna recom- 
mends, after much experience, calomel in quarter or half- 
grain doses twice a day; also at the same time inunction of 
an eighth or a fourth of an ounce of mild mercurial ointment 
into the shaven scalp once in twenty-four hours. The head 
is to be kept constantly covered with flannel, to prevent any 
check to perspiration. After a lapse of six or eight weeks, 
diuretics in the form of acetate of potash, or tincture of 
squills, or both, are to be given with the mercury. Counter- 
irritation by issues in the neck are also advocated by him to 
be kept open for months. Compression of the head by 
bandaging, or by well applied strips of adhesive plaster, are 
also to be applied over the whole cranium. Puncture of the 
skull, if the fluid is arachnoidean, may also prove of service, 
— not so if the fluid is ventricular. It is to be done with a 
small trocar and canula at the coronal suture, about an inch 
and a half from the anterior fontanelle, taking care to avoid 
the longitudinal sinus. The fluid must be slowly evacuated, 
and compression of the skull carefully maintained for many 



264 MERCURIAL POISONING— MILIARIA. 

weeks while the fluid is allowed to drain away. The opera- 
tion has been successful in very young children. 

Hygienic measures ought to be of the first importance in 
the rearing of delicate children, so as to prevent if possible 
the development of those conditions which lead to effusion 
of fluid within the cranium. During the course of the dis- 
ease the diet should be slops and light puddings. 

In congenital hydrocephalus the unassisted efforts of 
nature are incapable of effecting a cure, and it is extremely 
problematical if medicine is of any use. When, however, the 
case is deemed hopeless, the propriety of evacuating the 
water by means of an operation may be entertained. Golis 
has given the names of twenty-seven writers who have ex- 
pressed themselves in favor of it, especially if the fluid be 
slowly evacuated, and at several repetitions of the operation; 
yet he himself, along with seven or eight others, proscribe it 
altogether as cruel and useless. But it has been successful; 
and when the operation is performed, it seems an axiom that 
the fluid should be allowed to escape gradually, for otherwise 
extreme faintness and collapse may be expected. In such 
cases small doses of. ammonia, or a few teaspoonfuls of 
brandy and water may revive the little patient. Should re- 
action take place, however, at a snbsequent period, a few 
leeches and a cold lotion ought to be applied to the head. 
It seems also determined that the younger the child the 
greater are the chances of success; for if it lives a few years 
the sutures of the craniun, though open at the top, are united 
by bone towards the base of the skull, and thus present a 
mechanical obstacle to their closure; consequently, the 
operation is more apt to fail. If this disease, though exist- 
ing at birth, should not develop till later in life, blisters, 
mercury, and iodide of potassium to salivation are the 
remedies mostly relied on. 

Mercurial Poisoning. — Definition. — A series of morbid 
phenomena, especially peculiar tremors, with cachectic and 
cerebral symptoms, induced by the absorption of mercurial 
inhalation of vapors from mercu ry or its salts, or from the 
medicinal administration of the salts of mercury in continu- 
ous small doses. 

The Treatment is similar to that already described for 
the elimination of lead. 

Miliaria. — Definition. — An eruption of innumerable mi- 
nute pimples, with white summits, occurring in successive 



MORBILLI — MUSCULAR ATROPHY. 265 

crops upon the skin of the trunk and extremities, preceded 
and accompanied with fever, anxietas, oppression of respi- 
ration, copious sweats of a rank, sour, fetid odor, peculiar 
to the disease. The base of the pimples and the skin around 
are red and irritable. 

Treat??ient of the disease appears to consist in cooling 
drinks, purgatives, and antiphlogistics. 

Morbilli — See Measles. 

Mumps. — Definition. — A specific fever with inflammation 
of the parotid and other salivary glands, which is contagious 
and sometimes epidemic. 

Treatment. — Constant hot fomentations (after leeching in 
severe cases) should be applied to the swollen parts. The 
maintenance of a constant but gentle action on the bowels, 
by saline cathartics, must be attended to. Absolute rest 
ought to be enforced, a farinaceous diet enjoined, and no 
irritating applications ought to be applied to the swollen 
glands. The disease runs a definite course, and is not likely 
to terminate unfavorably. 

MllSCle, Spasm Of. — Definition. — An affection charac- 
terized by pathological contractions of muscles, some pain- 
ful and some not, but manifested only during the exercise of 
certain voluntary or instinctive movements (Duchenne). 

Treatment in all these cases must be directed towards the 
removal of the probable cause, and improvement of the gen- 
eral health (see Scrivener's Palsy). 

Muscular Atrophy, Progressive. — Definition. — A pe- 
culiar wasting of muscles, with atrophy of their substance, 
associated with lesions of grey matter in the centre of the 
cord — namely, wasting of the ganglionic cells of the anterior 
horns, with oleo-granular degeneration, and of the anterior 
roots of the nerves of the spinal cord, and attended by 
paralysis. 

Treatment of wasting palsy ought to be strictly a restora- 
tive one , believing that the disease is one of nutritional de- 
terioration of the nervous centres. Preparations of wine 
and cod-liver oil, with localized faradization, are the most 
likely agents to improve the condition of the body (Althaus). 
Local means will aid the hygienic — namely, methodical 
exercise and douche baths, or cold mineral baths; so also 
thermal or sulphur baths, and galvanism. Frictions, 
with stimulating liniments (such as camphor liniment), are 



266 MUSCULAR RHEUMATISM. 

also favorably spoken of (Duchenne, Gross, Meyer, Roberts). 
"Faradization" ought to be practised, at least three times a 
week, for from five to ten minutes each, and continued at 
least a month before it is given up, if negative results are 
only obtained. Every muscle ought to be faradized in a 
special manner, according as it has suffered more or less in 
its electric contractility and nutrition. The power of the 
current ought never to be strong. When the sensibility of 
the muscle returns, the intensity of the current may be 
diminished. Its application should never be protracted 
beyond ten or fifteen minutes at the most — one minute, on 
an average, being allowed to each muscle, or distributed 
over several at a time. 

If, on the other hand, it turns out, as the searching exami- 
nations of Mr. Lockhart Clarke and others would tend to 
show, that these forms of progressive paralysis or '.' wasting 
palsy " are always associated with disease of the spinal cord, 
the efforts of treatment should, in the first place, be directed 
to that part of the cord corresponding to the connections of 
the nerves with the site of lesions — the line of treatment to 
be pursued being determined by the general symptoms. 
The application of the constant current of electricity — the 
positive electrode being placed in the region of the cervical 
sympathetic, and the negative electrode upon the cervical 
and upper dorsal regions of the spine — has been followed by 
long amelioration, if not by positive cure, in the hands of 
Remak and Benedikt (Clymer, in New York Medical Jour- 
nal, 1866, Vol. III). 

Muscular Rheumatism. — Definition. — Pain in the mus- 
cular structures, increased by motion. 

Treatment. — In muscular rheumatism, the local appliances 
which ensure rest and warmth afford most relief. In lum- 
bago nothing is so instantaneously beneficial as strapping the 
back from the level of the "seat " upwards, in imbricated 
layers of straps of adhesive sticking-plaster — emplastrum 
roborans — spread upon chamois leather, or the common 
warm plaster of the pharmacopoeia may be used (Tufnell). 
The patient ought to sit with his bare back before a large fire 
during the process. Calomel purgation is generally indi- 
cated, combined with rhubarb and soda, as the excretions 
are generally greatly at fault. The subcutaneous injection 
of morphia will generally give temporary relief. Opium may 
also be necessary internally ; and a course of bicarbonate of 
potash with iodide of potassium may be also indicated. 






MYELITIS NEURALGIA. 267 

Myelitis — See Encephalitis. 

Myocarditis. — Definition. — An inflammation of the mus- 
cular structure of the heart (extremely rare as an idiopathic 
disease), which becomes softened, flabby, and finally degen- 
erates in various ways. 

Treatment under such circumstances cannot be indicated 
beyond what has been stated under "Endocarditis;" but 
free stimulation will be called for. 

Nephritis, Suppurative. — Definition. — " Inflammation 
with suppuration of the substance of the kidney." 

Treatment. — The treatment of acute nephritis must be 
according to the usual principles of the treatment of inflam- 
mation, by keeping the patient at perfect rest, the applica- 
tion of hot fomentations and poultices, preceded or not by 
the local abstraction of blood or by dry-cupping. Blisters 
in such cases are dangerous, and ought to be avoided. The 
neutral salts, with opiates, are admissible in some cases, 
especially where calculi or gravel are sources of irritation. 
Castor-oil, or other purgative substances which do not act so 
immediately on the kidneys, are more useful, such as 
compound jalap powder or podophyllin. Should signs of 
abscess appear, the pus may be evacuated, as in the case of 
liver abscess, and with the same antisceptic precautions. 

Nettle-Rash — See Urticaria. 

Neuralgia. — Definition. — Excruciating pains occurring in 
the course of nerves, and in their area of distribution, usually 
of a shooting character, which flash with momentary intensity 
along the fibres of the affected nerve, occurring in par- 
oxysms composed of momentary shocks following one an- 
other in rapid succession (Bristowe) ; or returning with re- 
newed violence in a part after periods of temporary remis- 
sion, due to some unknown morbid state of the nerves of sen- 
sation or their centres, a symptom of some local lesion, or 
more commonly of a general affection or cachexia. 

Treatment. — When the cause of the neuralgia can be dis- 
covered, its removal is the obvious procedure to follow. 
There can be no question that the disease has often subsided 
under the use of various remedies ; but the tendency in neu- 
ralgia to a spontaneous intermission is so great, that it is 
doubtful whether in any case medicine can be said to have 
cured it. Opiates are unquestionably serviceable in mitigat- 
ing the sufferings of the patient, and perhaps in influencing 
the disease, but not to the extent generally supposed. Bella- 



268 NEURALGIA. 

donna, both internally and as a plaster, may sometimes re- 
lieve the pain. Stramonium and opium have a similar tem- 
porary effect. Chlorodyne is also to be recommended ; and 
the tinctures of gelseminum and of guarana. 

The remedies of most value are the diffusable stimulants, 
such as sal-volatile, hot tea, quinine, chloral, and croton- 
chloral, in full doses, and alcohol in small doses, blistering, 
the application of ammoniacal fluid to the skin immediately 
over the painful nerves, and the endermic application of 
morphia. These remedies act by increasing the supply of 
blood to the painful nerve, and, pro tanto, heightening its 
vital energy (Anstie, op cii., p. 84). The most speedy way of 
obtaining a temporary relief is certainly the application of a 
local stimulant, and more especially of some volatile agent, 
such as mustard, or, still better, chloroform diluted with seven 
parts of some simple liniment, such as belladonna (Anstie). 
A rapidly acting blistering fluid is still more effective. But 
the more profoundly the general health has been affected, 
and especially the greater the degree of anaemia, the more 
necessary is it to join with the use of stimulants (both local, 
such as above mentioned, and general, such as the carbonate 
and muriate of ammonia, taken in five and ten grain doses 
respectively), a treatment directed to improving the condition 
of the blood by "food tonics," such as cod-liver oil, arsenic, 
or steel, or a combination of some of them, joined with the 
use of local stimulation by means of frictions with dilute 
chloroform, and the manipulations of the scientific " sham- 
pooer " (Anstie, op at., p. 87). Dr. Radcliffe reports favor- 
ably of the hypophosphite of soda, and believes that the phos- 
phorus of this salt acts directly as a food to the nervous tis- 
sue. The subcutaneous injection of small doses (}i to J of 
a grain) of morphia in solution will give temporary relief, and 
is especially useful to those patients who are obliged to go 
through an ordinary day of labor (Anstie, op. tit., p. 87). 

When these or other general remedies have proved insuffi- 
cient, recourse has been had to local remedies. The most 
efficient of these applications is the alkaloid aconitina, rubbed 
upon the pained part in the form of an ointment, in the pro- 
portion of one or two grains to one drachm of lard. A more 
convenient and efficient application is the " anodyne amyl 
colloid," prepared by Messrs. Ferris & Co., of Bristol, from 
hydride of amyl, aconitina, veratria, and etheral collodion. 
Morphia similarly used, and blisters, have often exercised a 
beneficial effect upon the disease. Holding the head over 






NEURALGIA. 269 

steam, and the warm bath, are sometimes beneficial in cases 
of facial neuralgia. The belladonna plaster is also a favorite 
application.* When the neuralgia is superficial, compresses 
steeped in a solution of atropiahave a good effect. For this 
remedy Trousseau recommends the following formula : — 

3,. Atropiae sulphatis, gr. v. ; Aquoe distillatce, 3 iii. ; solve. 
Renew the compresses several times in the twenty-four hours. 
Continue them for at least an hour each time, and cover them 
with oilskin, to prevent evaporation. 

When general and local applications are unsuccessful, the 
cause may be sought for in a diseased tooth or stump, and in 
a very few instances an exostosis of the stump has been dis- 
covered, removed, and the disease cured. Sometimes,' how- 
ever, even when the patient submits to have every tooth in 
his head drawn, no relief or benefit may result. The division 
of a nerve is sometimes had recourse to ; but even this opera- 
tion is very uncertain. Where the causes of neuralgia cannot 
be removed, modes of treatment which greatly modify the 
change of tissue and the nutrition of parts are often benefi- 
cial. Chief among these is the use of electricity ; and 
Niemeyer gives the results of his experience in the following 
propositions : — 

" 1. In treating neuralgia Avith the induced current, it is 
best to employ the metallic electrodes known as the electric 
brush. While one electrode, containing a moistened sponge, 
is held in one of the patient's hands, or against any part of 
his body, we stroke the brush along the course of the affected 
nerve ; if there are any specially painful points, we allow the 
brush to remain over them rather longer {electric moxce). 

" 2. Many cases of neuralgia, which had been previously 
treated without benefit by the most varied remedies, were 
completely and permanently cured in from twelve to twenty 
applications, or even sooner. In other cases no benefit or 
cure was effected." 

" 3. The first sitting shows whether the neuralgia can be 
cured by the induced current. We can only expect a cure 
where the pain is decidedly relieved, or entirely disappears, 
immediately after the first electrization, even if it should only 
be for a short time. If this temporary result do not take 
place, the continuation of the treatment will also prove inef- 
fectual. 

" The application of the induced current as above directed 
is very painful. The current employed ought not to be of 
greater intensity than the patient can easily bear ; the appli- 



270 NEURALGIA. 

cations should also be of short duration and frequently re- 
peated. It is only after the patient has actually experienced 
benefit that he suffers it with patience." 

The constant current is far more effective than the Faradic 
in neuralgia. Some cases that have been treated without re- 
sult by the Faradic current have been cured by the constant, 
but never by the reverse. Niemeyer places both poles along 
the affected nerve, and, without attending to the course of 
the current, holds the zinc pole on the most painful part and 
on those parts where the nerve approaches nearest to the sur- 
face, as at the supra or infra-orbital foramen, or at the zygo- 
maticofacial foramen, or at the sciatic notch. If it be pos- 
sible to get the nerve between the poles, as in the cheek or 
nose, he introduces one pole into the mouth or nose to the 
point whence the pains radiate, while the other is placed at 
the corresponding point on the skin. " At first the applica- 
tion of the constant current is not particularly painful ; but 
an unpleasant, burning, piercing pain soon commences, and 
gradually increases ; and where the number of electric ele- 
ments is large, it may become 'unbearable. 

" The changes induced in the skin at the point of applica- 
tion of the constant current, if the electrodes be applied for 
a length of time, are far greater than those caused by the in- 
duced current. They not only consist in a lively erythema, 
a decided swelling of the skin, and an increase of the subja- 
cent tissue ; but papules and blebs arise on the skin, particu- 
larly at the positive pole. It the action continues long, the 
surface of the elevations sloughs off. These changes take 
place not only at the point of application, but occur 
equally, or at least similarly, in the deeper parts, as is 
shown not only by the increase in volume of the sub- 
cutaneous tissue and muscles, but also by the following ex- 
periments (Erb), which show a great deal about the mode of 
action of the constant current in neuralgia and other neu- 
roses, as well as in some diseases of the muscles and joints: 
If we cross the forearms, placing the volar surfaces in con- 
tact, and apply the electrodes to their dorsal surfaces, there 
will be reddening not only of the parts to which the elec- 
trodes are applied, but of the corresponding points on the 
anterior surfaces. Generally, relief immediately follows the 
application of the constant current, just as it does that of the 
induced current; but occasionally the pain is at first in- 
creased, and that should not always induce us to stop the 
treatment. There seems to me no doubt that the curative 



NEURALGIA. 271 

action of the constant current, in most cases of neuralgia, is 
to be explained by the modification of the circulation, endos- 
mosis, or change of tissue in the diseased nerve, its neuril- 
emma, or the parts around. This ' catalytic action ' may 
result from the chemical disintegration induced through the 
nerves, or the attraction of the constituents of the nutrient 
fluids toward the pole, or it may occur in some other way " 
(Niemeyer). 

Narcotics, in the form of hypodermic injections of solutions 
of morphia, are of great value, and it is immaterial whether 
the injection is made near the seat of pain, or at a remote 
distance from it. " Subcutaneous injections of morphia con- 
stitute the only decided and effectual, and truly invaluable, 
method of treating neuralgia" (Von Pitha). The hypoder- 
mic syringe and the morphia solution are now almost as in- 
dispensable accompaniments of the physician as the stetho- 
scope and thermometer. Its use, however, is attended with 
similar bad results as the taking of opium in any other form. 
The dose must be gradually increased, and the remedy can- 
not easily be given up. If it is omitted the patient feels dull, 
weak, uncomfortable, nervous, and trembles from head to 
foot, as after an alcoholic debauch. As a palliative it is 
invaluable, to the extent of one-sixth to one-third of a grain 
of morphine, injected hypodermically. But in slight cases, 
and in sensitive persons, and in the young, very much smaller 
doses may relieve the pain — e.g., the twentieth to the twelfth 
of a grain. In severe and persistent cases the dose has to 
be increased; and it is very desirable not to have recourse to 
such hypodermic injections oftener than twice daily. It is 
necessary also to employ the remedy with proper caution, 
with reference to the patient's individuality or idiosyncrasy. 
The hypodermic treatment with morphia must be commenced 
tentatively in small doses. The first dose of a morphia in- 
jection for an unknown individual must not be more than 
one-twelfth of a grain; and in very sensitive and delicate 
women and young people not more than one-twentieth, or 
even yet less. If the patient is the subject of that peculiar 
idiosyncrasy of extreme sensitiveness to opium, symptoms of 
poisoning may supervene. Thus, there may be syncope, 
spasm of the heart, or an asthmatic paroxysm, the skin being 
covered with a cold sweat. Fresh air should at once be ad- 
mitted through opened windows, while the patient's face is 
diligently fanned. An assistant should also bathe the face 
and temples, as well as the bared chest, with vinegar, and 



272 NEURALGIA. 

these parts are to be sprinkled at the same time with cold 
water. A strong decoction of coffee is to be administered as 
an enema, or, when possible, given by the mouth; and, in 
extreme cases, artificial respiration must be resorted to. In 
most cases these means will succeed, providing that the dose 
has not been too large. When the vomiting and disposition 
to syncope persist without yielding to the usual measures, a 
careful and interrupted inhalation of chloroform may be use- 
ful. If there is a constant disposition to nausea and sickness 
after the hypodermic use of morphia, it may be counteracted 
by adding from a quarter to a third of the tincture of bella- 
donna to the morphia solution, then the extract, and, finally, 
minute quantities (about one-hundredth of a grain) of the 
sulphate of atropia. The extract answers best (Von Pitha). 

The injection should be projected into the subcutaneous 
tissue, and not into the skin itself; and this may be secured 
by pinching up a fold of skin, care being taken not to make 
a double perforation in it. Well known or visible vessels or 
nerves are to be avoided. The places most eligible for the 
injections are — the external parts of the arm and thigh, the 
back, and the integument of the abdomen and nates. The 
face and neck should be avoided; and the painful regions 
ought not to be punctured. 

" With respect to the preparation to be employed, it may be 
stated that the acetate and hydrochlorate may be used in- 
differently. Only in cases in which very large doses are given, 
as above a grain, need the acetate be preferred, on account of 
its greater solubility. It will form a clear solution in six parts of 
water, whereas the hydrochlorate requires twenty parts. Hot 
water will dissolve it in ten parts, but, on cooling, half of the 
alkaloid is precipitated; so that if a concentrated solution is 
wanted, it has to be prepared only just before using it. On 
the other hand, the acetate requires great care in keeping it 
in a cool place and shielded from the light. The solution 
should always consist of morphia and distilled water, without 
any addition whatever. The favorite addition of glycerine 
has the disadvantage of causing white flocculi to be precipi- 
tated from the originally clear liquid. Belladonna, however, 
may be added, for the reasons already stated, with great ad- 
vantage; and although the solution is rendered somewhat 
turbid, its efficacy is not diminished. It is very desirable 
that similar combinations with different other substances, 
and especially other narcotic alkaloids, should be thoroughly 
investigated " (Von Pitha). 



OESOPHAGITIS. 273 

Frictions of the skin with veratrine ointment, in the, pro- 
portion of gr. iv. to-gr. x. of veratrine to 3 i. of lard; or with 
aconite ointment, in the proportion of one grain of aconite 
to one drachm of lard, have also been used with advantage. 
The application of cold water sometimes, but only excep- 
tionally, does good, especially if the pain is attended by 
heat — applied as a compress, or as a fine douche. Warmth 
by means of a hot iron, a stream of warm water, or as a warm 
cataplasm, may also afford relief. Richardson's spray pro- 
ducer has also been of use; and also acupuncture as recom- 
mended by Teale, especially in the neuralgia of joints persist- 
ing after rheumatism or spasm. As internal remedies chloral 
and bromide of potassium combined are of great service. 

The treatment of sciatica consists in following out, as far 
as possible, the removal of the causes and circumstances al- 
ready noticed as producing the disease. In the rheumatic 
form, the warm baths are most useful, especially the syste- 
matic treatment at Neuenahr, Wildbad, Wiesbaden, Teplitz, 
and Bath. Iodide of potassium, in large doses, and sulphur, 
especially in the form of the Chelsea pensioner, appear to do 
most good. Of other specific remedies Niemeyer mentions 
the induced, and still more, the constant current of electricity 
as rarely failing to do good. Oil of turpentine, as an elect- 
uary, is also recommended in the following : — 

3- 01. Terebinth. 3i-; Mell. 3 i., of which a tablespoon- 
ful is to be taken twice a day. This is very highly spoken 
of by Romberg. 

With regard to the treatment of mastodynia or irritable 
breast, — a plaster worn on the breast, if composed of anodyne 
elements, may soothe the pain and prevent the gland being 
touched by the patient, and it as well may give support to 
the breast. Cooper recommends the soap plaster with ex- 
tract of belladonna, and the following pills : — 

Ijt Ext. Conii, Ext. Papaver, a a gr. ii.; Ext. Stramonii, 
gr. ^ to ^, are mentioned by Romberg as useful. 

Oesophagitis. — Definition. — Inflammation of the textures 
of the oesophagus. 

Treatment of oesophagitis is by small local bleedings, by 
warm cataplasms to the neck, and by moderately acting on 
the bowels. In the treatment of the more chronic forms 
some sedative is essential. There is always some danger, in 
the use of the probang, of rupturing the canal, or of causing 
an ulcer. When the case is hopeless, from the small quan- 
tity of aliment which reaches the stomach, life may yet be 
18 



274 

prolonged by enemata of soups, milk, egg, wine or other 
nutritious fluid matters. The question of an artificial 
opening into the oesophagus or the stomach may have to be 
considered. 

Osteo- Arthritis, Chronic. — Definition. — An affection 
characterized by pain, stiffness, and deformity of one or 
more of the joints, associated with the deposition of new 
bone around them. 

Treatment. — Chronic osteo-arthritis must not be treated 
either as gout or as rheumatism. Colchicum is considered 
by Dr. Garrod to be generally injurious, and so also is alka- 
line treatment. The course of management may be shortly 
indicated as follows: — Gregory's powder at bedtime, and 
more active aperients at regular intervals, are required as a 
necessity. The action of the skin ought to be encouraged 
by hot-air baths, the frequent use of the Turkish bath, and 
Dover's powder at bedtime. Warm bathing is generally at- 
tended with relief, and recourse should be had to the mineral 
springs of high temperature. Schwalbach, Spa, Wildbad, Neu- 
enahr, and Tunbridge Wells, are the best. Guaiacum, if borne 
by the stomach — combined or not with sulphur, and taken as 
an electuary in glycerine — is of great assistance (Garrod). The 
free use of dilute phosphoric acid is recommended by Mr. 
William Adams. Iodide of potassium is also well spoken of. 
Whichever of these remedies may be considered suitable for 
any particular case, it ought to be steadily persevered in for 
several weeks. Warm clothing and residence in a warm 
climate, during the winter months, are necessary elements 
for increasing the comfort of the patient. If much emaci- 
ation has resulted, cod-liver oil and fats must be prescribed, 
combined with the usual tonic remedies — quinine, iron, 
strychnia, arsenic, and mineral acids — according to the 
nature of the case. The local remedies must be regulated 
by the surgeon. Chief of these Dr. Julius Althaus has used 
with advantage that most active stimulant of nutrition — the 
continuous galvanic eurrent. It acts as a general tonic to 
the system, more especially to the nervous system; and re- 
lieves one of the chief complaints, want of sleep, when 
hydrate of chloral fails. The best mode of application for 
this purpose is to direct the positive pole, armed with a con- 
ductor of large surface, to the cervical spine, while the nega- 
tive pole, Similarly armed, is placed on the pit of the stom- 
ach. A gentle current, which even patients of exquisite 



PACHY-MENINGITIS PALSY, SHAKING. 275 

sensibility can well bear, is thus allowed to flow for from 
three to five minutes in the direction just described. By 
this application, the base of the brain, the spinal cord, and 
the cceliac plexus of nerves, are simultaneously brought 
under the influence of the current. It also relieves pains, 
for which object the constant current must be applied to 
the suffering parts, so that the positive pole, armed with a 
small electrode, is made to touch the sore points; while the 
negative, connected with a. large electrode, is placed in the 
neighborhood. The current used may in this instance be 
somewhat more powerful than where it is employed for 
general tonic effects; and if a short application, say of one 
or two minutes, be not successful, this may be extended to 
four or five minutes. The effect is, in many instances, 
almost magical, inasmuch as pain, which has been fixed in 
some particular spot for months and years, is, as it were, 
charmed away by one or two applications. If such treat- 
ment is followed up for a sufficient length of time, even 
extensive deformities may be improved {Brit. Med. Jour., 
Sept. 28, 1872). 

Pachy-Meningitis. 

Treatment. — Circumscribed suppurations, when recognized, 
must be dealt with by the surgeon, under rigid antiseptic pre- 
cautions. Evaporating lotions or ice to the head or spine 
are also indicated. Free action of the bowels (especially of 
the lower bowel by .aloetic laxatives) should be maintained. 
Circumstances may also indicate iodide of potassium, and 
pain is best relieved by large doses of opium or morphia. 
The patient ought to be kept perfectly at rest. 

Palsy — See Scrivener s Palsy. 

Palsy^ Shaking. — Definition. — Involuntary tremors, con- 
tinuous and permanent, with lessened muscular power, ag- 
itating various members increasingly, allowing no peace; and 
while purposed movements may exaggerate the shaking, re- 
pose does not cause its disappearance, and sleep alone puts 
a temporary stop to the spasmodic agitation of the affected 
members. The affection may commence in the hands, arms, 
or head, and gradually extend over the whole body. 

Treatment. — Hyoscyamine is a palliative merely, while 
strychnine, ergot of rye, hyoscyamus and opium, nitrate of 
silver, and Calabar bean all aggravate the tremors. The use 
of the continued current of a galvanic pile has been attended 
with success in the hands of Remak and Russell Reynolds. 



276 PARALYSIS, LOCAL. 

Paralysis, Local.- — Definition. — Paralysis limited to par- 
ticular sets or groups of muscles. 

Treatment, — Paralysis due to lesions which are destructive 
of the nerve are beyond medical aid. In cases suitable for 
treatment, and within the first few days, the agents used with 
most benefit are, — blood-letting by leeches behind the ear of 
the affected side, or over the mastoid region. They ought 
to be applied repeatedly, especially if any pain exists on 
pressure in that region. Blisters, with dressings to keep them 
open, medicated by veratria or strychnia (fa to \ of a grain 
sulphate of strychnia or of veratria), mixed with five or six 
times their weight of pounded sugar. Electrization in the 
form of faradization by a Stohrer's two-celled volta-electric 
machine; or in the form of an interrupted galvanic current, 
from a continuous current battery (as from a Muirhead's 
battery of fifteen cells), the number of cells being very grad- 
ually increased, are agents of much service. 

In using faradization each facial muscle should be sepa- 
rately influenced, instead of attempting to pass the current 
through the facial nerve. The muscles are thus more pow- 
erfully influenced, and they are more apt to regain voluntary 
contractility at different periods, some muscles before others. 
At first the apparatus should be one capable of producing 
currents with very rapid intermissions; but when any mus- 
cles begin to contract, the intermissions should be few, and 
the sittings at long intervals (three time* a week, for two or 
three minutes only at a time), otherwise contraction of the 
muscles is apt to increase and become incurable. The vol- 
taic current, from a continuous current battery, induces con- 
tractions when the circuit is closed and when it is opened, 
and more powerfully at the moment of closure. It is said 
to restore to palsied muscles the power of contracting under 
the influence of faradization. When improvement follows 
the use of the voltaic current from a continuous battery, the 
number of the cells should be gradually increased as the 
muscles get less susceptible to their influence, and then the 
battery may be used oftener. One of the electrodes should 
be gently moved along the surface of the muscle, just as the 
brush is used in faradization. During the first weeks it 
may not be used oftener than once weekly, commencing with 
six to ten of Stohrer's elements, 

When contracture of muscles supervenes, they ought to be 
stretched or pulled out mechanically. To remedy contrac- 
tion of the buccinator, Duchenne recommends the use of a 



PARALYSIS, ACUTE SPINAL OF ADULTS. 277 

small billiard ball worn for a long time inside the cheek, to 
be replaced after a time by a larger one. The late Bazire 
gave favorable testimony to the value of this mechanical 
aid. 

The daily action of the bowels ought to be carefully 
regulated, especially by such medicines as keep the colon 
in functional activity. Bichloride of mercury (corrosive 
sublimate) in small doses, continued till the gums are 
slightly tender, is sometimes of service. In - cases where 
rheumatism prevails, or periostitic affections, small doses 
of iodide of potassium, persevered in for a lengthened 
period, are of service, with the frequent use of phosphate 
of soda as a daily morning aperient. 

Treatment of most of the forms of local paralyses is main- 
ly by the continuous voltaic current to the muscles when the 
acute symptoms have passed away, and when no fever or lo- 
cal signs of inflammation exist. The use of cutaneous fara- 
dization, on a dry surface with a feeble and slowly intermit- 
tent current, has also been strongly recommended by Du- 
chenne. Friction, stimulant applications, and blisters are 
also of use. 

Paralysis, Acute Spinal of Adults. — Definition. — A 

sudden feverish attack, with such cerebral phenomena as 
deafness, coma, delirium, or general convulsions, soon fol- 
lowed by a rapidly developed and complete paralysis, vari- 
ously distributed over the trunk and extremities; but gener- 
ally in the form of paraplegia. There is entire relaxation of 
the paralyzed muscles; an absence of any severe disturbances 
of sensation; and there is no paralysis of the sphincters nor 
bedsores. The original paralysis is not progressive; but im- 
provement gradually takes place as to the restitution of 
movement up to a certain point, which is not uniform. In 
the end the power of movement in some part is lost forever; 
a paralytic and withered limb for life is all that can be hoped 
for (Professor W. H. Erb). 

Treatme7it. — The acute myelitis, if detected, first demands 
attention. Local abstraction of blood by leeches or cupping 
should be had recourse to over the cervical and lumbar en- 
largements. The bowels should be freely moved by cathar- 
tics, followed by iodide of potassium in appropriate doses. 
Rubbing in of mercurial ointment and counter-irritation may 
afterwards be employed the whole length of the spine, or 
blister, plaster, or painting with the tincture of iodine. Dr. 
Althaus has most confidence in the subcutaneous injection 



278 PARALYSIS, ACUTE SPINAL OF ADULTS. 

of ergotine (Bonjean's solution in diluted water), one-fourth 
grain for a child from one to two years of age, one- third 
grain for a child from three to five years, and half a grain 
for children from five to ten years, and a grain for patients 
upwards often years; to be repeated as symptoms indicate, 
once or twice a day. When acute symptoms have subsided, 
the diseased area within the cord should become the main 
object of treatment, by induction of the catalytic action of 
the voltaic current. A large electrode, which will cover the 
entire diseased area, is to be placed over the lumbar or cer- 
vical enlargement, while the other is to be applied to the an- 
terior surface of the trunk. First the anode, and then the 
cathode, are to act alternately for from one to two minutes 
at a time, with, a moderately strong current. This treatment 
must be continued for a long time, or repeated at intervals 
for several years. The faradic current is not to be used at 
this period. Such are the recommendations of Erb. They 
differ somewhat from the injunctions of Althaus. " It being 
most important that the voltaic current should pass -through 
the anterior cornua, it is better to have one pole on the spine 
and the other on the front part of the body, than to place 
both electrodes to the spine. If the cervical cord has to be 
acted upon, place the positive pole to the nape of the neck, 
and the negative to the manubrium sterni. When the lum- 
bar enlargement is diseased, the positive pole is put to the 
loins, and the negative a little below the umbilicus; while, 
when the dorsal cord has to receive the voltaic influence, the 
positive pole should be slowly guided along the whole dorsal 
spine, the negative being left stationary at the ensiform car- 
tilage " (Althaus) 

If electric contractility remain, much may be hoped for, 
so long as nerves and muscles have not altogether degener- 
ated. The principles of treatment are the same as have been 
advocated in analogous diseases — namely, restorative and 
not depressant. The general health must be improved by 
the use of baths, with a strong and abundant diet; the use of 
cod-liver oil, and prolonged sojourn in mountain air. The 
systematic, active, and persistent application of the voltaic 
current of electricity is the best means of preserving the func- 
tions of the implicated muscles, and of arresting their atro- 
phy and degeneration, provided all other hygienic arrange- 
ments are maintained which have already been insisted on 
as to food, clothing, ventilation, and open air. The cathode 
is to be applied over all the paralyzed muscles and nerves; 



PARALYSIS AGITANS PARALYSIS, BULBAR. 279 

while the anode is best placed upon the vertebral column at 
the height of the main lesion. The strength of the current 
should be such as to produce distinct twitchings and lively- 
redness of the skin. The faradic current may, however, still 
be used when the muscles retain their faradic irritability. 
The faradic application is to be made with moist electrodes. 

Mild purgation may be required; alteratives, especially 
small doses of mercury, continued for a long time, have been 
of service; and so also have quinine, iodide of potassium, 
and iodide of iron. 

Friction, kneading, squeezing (massage), and shampooing 
ought also to be persevered in. Three or four small circu- 
lar wooden balls, about the size of a walnut, shut up in a 
box, with holes in its cover, so as to expose one-third of the 
surface of the balls on a uniform level, makes a good sham- 
pooing apparatus. 

Paralysis AgitailS — See Palsy, Shaking. 

Paralysis, Bulbar. — Definition. — A chronic and pro- 
gressive affection of the bulbar nuclei, in which there is di- 
minution and subsequent loss of the motor power of the 
tongue, soft palate, and lips, associated with structural 
changes in the central nuclei and roots of the motor nerves 
which supply the affected muscles. The disease progresses 
always more or less rapidly to a fatal termination. 

Treatment. — Faradization is of doubtful efficacy at the 
commencement, but gives relief at later periods, by tempo- 
rarily restoring function to the affected muscles, to the les- 
sening of the trouble of deglutition, and by exciting the re- 
spiratory acts. 

Dr. Dowse relates one case of cure under his care {Brit. 
Med. Journal, March 11, 1876, p. 321). The bulbar paraly- 
sis came on after a severe epileptic attack. The paralyzed 
parts were brought under the influence of galvanism, and in- 
jections of one-sixth of a grain of strychnia, and one-twen- 
tieth of a grain of atropia were daily used to the lower ex- 
tremities. At first the induced current from a two-celled 
Stohrer's battery was several times applied to the tongue 
without any result ; after this the continuous current from 
six cells of Stohrer's battery was applied, and with the best 
results, for the tongue was quickly protruded, and as sharp- 
ly retracted. For some days, however, he had no voluntary 
power over it ; but the use of the daily galvanic stimulus 
shortly ensured this, and articulation soon became perfect. 



28o PARALYSIS, GENERAL PARALYSIS OF THE INSANE. 

It was for some time almost inaudible, and the letter R was 
the most inarticulate of all the consonants. With this the 
power of swallowing soon returned, so that he had complete 
co-ordinate voluntary power over those parts supplied by the 
bulbar nerves. The last to regain power and sensation were 
the lower limbs. The muscular atrophy here was so ex- 
treme that nothing but the tibiae and integuments appeared 
left ; but galvanism, frictions, and injections gave excellent 
effects. He also took cod-liver oil, quinine and phosphor- 
us. Instead of his being a mute, helpless, and emaciated 
creature, he had complete voluntary power over every part 
of the body. 

When initial pains in the head and neck point to the com- 
mencement of myelitic changes, Professor Kussmaul recom- 
mends the repeated application of dry-cupping glasses to the 
nape of the neck every five days, and in full-blooded strong 
persons he would order blood to be abstracted at the first 
cupping. Afterwards he would permit the cautious tentative 
use of the shower douche, and even the jet douche for strong 
persons. Food and drink of a stimulating kind must be 
avoided during the first months. As to medicines, nitrate 
of silver, administered early, is deserving of most confidence. 
He also recommends galvanization. It may be necessary to 
administer food through an oesophagus tube, or by nutrient 
enemata. 

Paralysis, General. — See Paralysis of the Insane. 

Paralysis, Labio-GUosso-Laryngeal. — See Paralysis > 

Bulbar. 

Paralysis Of the Insane. — Definition. — An incessantly 
progressive form of general paralysis, in which the cineri- 
tious substance of the brain is the seat of cloudy swelling of 
its minute elements — the ganglionic brain-cells — with lesion 
of minute blood-vessels and increase of connective tissue, as- 
sociated with peculiar disorder of the intellect, general fail- 
ure of nerve power, muscular debility, frequent blood extra- 
vasation (haematoma), convulsions of the nature of apoplexy 
and epilepsy combined, and tending to involvement of the 
whole brain in degeneration, softening, and atrophy, so that 
general and complete paralysis of body and mind results. * 

Treat?nent. — Regarding the disease from the commence- 
ment as essentially a chronic form of parenchymatous in- 
flammation, confined at first to the convexity of the fore- 



PARAPLEGIA. 281 

half of the hemispheres, and frequently tending to meningitis 
more or less complete, Dr. Meyer, (following Jacobs of 
Siegberg) has adopted the method of counter-irritation in its 
treatment. He keeps open for some months a suppurating 
surface. For this purpose the head is to be shaven of hair 
over the centre of the fore part of the skull-cap for a space 
as large as half the palm of the hand. On the central por- 
tion of this shaven space as much tartar-emetic ointment as 
will cover a shilling is to be rubbed in efficiently, and with 
some energy, with a linen compress or with the ball of the 
thumb. On a second application caution and gentleness are 
necessary, in order that the already loosened epidermis may 
not be torn away, for the deprivation of the cuticular layers 
causes exquisite pain. Considerable swelling very soon ex- 
tends over the frontal region and the face in the course of 
three or four days, which may even advance as far as the 
back of the head and neck. By this method an eruption of 
pustules does not take place ; but a large scab comes off in 
one piece by the frequent application of warm poultices, as 
soon as the place shows signs of swelling. As soon after the 
establishment of this suppurating process as the patient's 
strength will permit, the internal use of iodide of potassium 
is commenced. The diet must be digestible and of a highly 
nourishing character. The patient is to be sent out as much 
as possible for work in the open air, but only in the early 
and evening hours in the summer months. Exposure of the 
head to the sun or other source of heat is to be avoided. 

Paraplegia. — Definition. — A form of paralysis affecting 
the lower parts of the body, in which both legs, and perhaps 
also some of the muscles of the bladder and rectum, are 
paralyzed. 

Treatme7it. — In cases of reflex paralysis means must be 
taken, first — To diminish the external or peripheral irritation 
which causes the paralysis ; second, To improve the nutri- 
tion of the spinal cord ; third, To prevent the ill effects of 
rest on the paralyzed nerves and muscles. 

In cases of disease of the urethra or prostate, an injection 
of a solution of one grain of the extract of belladonna, in 
twenty drops of laudanum, is to be made into the urethra, 
and the injection should be retained for half an hour, or even 
an hour, after which some emollient decoction should be 
used, such as linseed tea, to wash out the passage. Every 
two or three days this operation should be repeated. If the 
bladder be diseased, Dr. Brown-Sequard advises a solution 



252 PEMPHIGUS. 

of one grain of the extract of belladonna, in twenty drops of 
laudanum, to be used as an injection, after complete emis- 
sion of urine. Injections of carbolic acid are also of use in 
counteracting decomposition of urine and epithelium in the 
bladder. If the prostate is enlarged, a suppository ought to 
be put at times into the rectum. One of the best supposito- 
ries for this purpose is composed of the following ingredients 
namely: — White sugar, white soap, and gum-arabic in pow- 
der, of each three grains; opium, in powder, a grain and a 
half; or belladonna extract, one grain; or both combined. 
These being mixed together, the mass is to be formed into a 
conical shape, and being dipped in melted wax, is ready to 
be introduced, when required, into the rectum (Simpson). 
When the irritation causing reflex paraplegia starts from the 
vagina or uterus, a pill of half a grain of the extract of bella- 
donna, with a grain of opium, surrounded by a piece of cot- 
ton wool, is to be introduced into the vagina, and made to 
surround the neck of the womb. By means of a thread it 
may be withdrawn so soon as pain ceases or diminishes 
(Trousseau, Brown-Sequard). Belladonna ought not to be 
used constantly. Opium, combined with strychnia, is of 
gseater use in reflex paralysis : and of all remedies, strychnia 
is best suited for promoting the second indication, which 
points to increasing the nutrition of the spinal cord. The 
dose combined with opium must be a small one — namely one- 
fortieth to one-thirtieth of a grain daily ; and when used 
alone, its dose may be one-twentieth of a grain ; and when 
employed together with belladonna, its dose must be still 
larger. In cases where no congestion or inflammation of 
the spinal cord exists, strychnia ought to be persistently em- 
ployed ; but its use to be suspended at once whenever it 
produces spasms, or even numbness of the feet in getting out 
of bed in the morning (Brown-Sequard). Sulphur baths are 
also productive of great benefit. 

The third indication — namely, to prevent the ill effects of 
rest on the paralyzed nerves and muscles — is best met by the 
employment of Voltaism and shampooing of the paralyzed 
limbs. Two or three applications, of ten minutes each, in a 
week, are sufficient ; but of all things it is necessary that the 
primary disease (causing by its persistent existence the reflex 
paralysis) should be cured or mitigated. 

Pemphigus. — Definition. — An eruption of large vesicles, 
filled with serous fluid, known as bullae. 

Treatment. — Dietetic and tonic, especially by quinine and 



PERICARDITIS. 283 

the mineral acids. Arsenic is said to be of use in obstinate 
cases, improving the general health. Emollient lotions, with 
or without opium, are useful local applications; also envel- 
oping the parts with india-rubber cloth dressed with sulphur. 

Pericarditis — Definition. — An inflammation of the fibro- 
serous membrane containing the heart, and investing it on 
its external aspect. 

Treatment. — The results of recorded treatment are unsatis- 
factory in the highest degree. Sir Thomas Watson writes, 
that " in a large proportion of the cases, whether they be 
treated well or ill, or not treated at all, the patients will seem 
to recover." Although blood-letting and calomel have hith- 
erto been regarded as two most efficient agents in accom- 
plishing the indications of cure, yet Taylor's analysis of cases 
shows that pericarditis may come on during salivation. The 
late Dr. Parkes informed me that he has seen this occur two 
or three times. It is, then, very doubtful if calomel ever 
does any good in pericarditis, notwithstanding that its use, so 
as to affect the gums, is advised by Watson, Graves, Stokes, 
and Fuller. Professor W. T. Gairdner, Drs. John Taylor, 
of Hudderford {Med. Times and Gazette, 1849), and J. Risdon 
Bennett, of London {Lancet, Dec. 6, 185 1), are all unfavor- 
able to such a use of mercury. In all the constitutional dis- 
eases in which pericarditis occurs as a complication, mercury 
is certainly contraindicated. In rheumatism and in Bright's 
disease, which furnish by far the larger number of cases of 
pericarditis, mercury is decidedly objectionable ; and it is 
now well-known to be productive of most injurious conse- 
quences in Bright's disease. Its use tends to weaken the 
heart and the system at large, and thus proves a source of 
additional irritation to the cardiac tissue, by undue reaction 
on the system. • 

Venesection is never to be practised. Treatment by bleed- 
ing may be carried out by leeches over the prsecordial region, 
or by cupping there in exceptional cases. When the pain is 
very marked, where it has strongly the characters of angina, 
leeches are to be applied in moderate numbers over the prae- 
cordial space. From four to six leeches (W. T. Gairdner) , 
ten to twenty (Niemeyer), so applied, accordingly to circum- 
stances, followed by fomentations, very commonly relieve the 
pain, and rapid improvement follows. To judge as to the 
repetition of blood-letting, the force of the heart must be ob- 
served, as indicated by the pulse at the wrist, by the actual 
strength of its impulse, and by the character especially of the 



284 PERICARIDITIS. 

first sound. If the impulse continues vigorous, and the first 
sound is undiminished, blood-letting may be repeated by the 
further local abstraction of blood by leeches ; but if the im- 
pulse has manifestly declined in force, while the first sound 
is lessened, great caution is required in the further abstrac- 
tion of blood. Fomentations, sometimes plain and some- 
times medicated with opium, are the chief local remedies to 
be afterwards relied on. In the second stage of the disease, 
when liquid effusion distends the pericardium, some reliance 
may be put in treatment by a blister of a large size over the 
prsecordia. Diuretics and iodide of potassium are also to be 
given. " Stimulants are often imperatively called for. The 
weakened heart requires to be supported and invigorated. 
This may be effected by the use of wine, and by the use of 
opium." If depletion has been excessive — if signs of mus- 
cular weakness supervene — if there be evidence that the 
heart, previous to the attack, was in weakened state — if a 
tendency to collapse or to a typhoid state manifests itself — 
tl we must give wine, quite irrespective of the physical con- 
ditions of the heart " (Stokes). Niemeyer recommends digita- 
lis as a suitable remedy in cases where the beat of thelieart 
is very frequent and insufficient, causing cyanotic and dropsi- 
cal symptoms. Its effect is then very markedly beneficial. 
Opium, in doses of one grain (/ <?., stimulant doses) every third 
hour, seems " to expend itself solely on the disease," and its 
beneficial effects are seen to result when it does not produce 
contraction of the pupil, nor headache, hot skin, furred 
tongue, nor constipation (Corrigan, Stokes, Graves, Sibson). 
Battley's solution is perhaps the most useful preparation. 
This remedy must be watched closely. There are two more 
important circumstances to be attended to — namely, that our 
treatment of pericarditis must depend upon the state of the 
diseases in which it is first discovered to exist; and it is im- 
portant to know that pericarditis from acute rheumatism calls 
for a totally different line of treatment from that associated 
with Bright's disease, or diffused inflammation of a low type 
(Sibson). In the rheumatic form, colchicum, in the form of 
a draught, and the administration of alkaline remedies, are 
indicated by the constitutional state. Warmth, especially 
moist warmth, and flying blisters are the best agents to pro- 
mote absorption. Niemeyer considers that the use of cold 
applications; such as ice-bladders, applied over the cardiac 
region, is deserving of great reliance; others condemn cold 
applications. 



PERICARDIUM, ADHERENT PERITONTTis. 285 

Paracentesis is to be recommended in all those cases in 
which the effusion is so great as to cause alarming distress, 
orthopncea, obstruction to the venous circulation, and serious 
interference with the heart's action. In such cases a fine 
exploring trocar and canula is to be introduced (not plung- 
ed), so as to make a valvular opening below the heart, either 
to the left of the xyphoid cartilage, or through the fifth in- 
tercostal space, close to its anterior extremity, and the fluid 
drawn off by means of a syringe (Sibson, in Med.-Chir. Re- 
view, July, 1854). The result may be merely palliative ; 
but, as Niemeyer justly remarks, "even to afford the sufferer 
opportunity, after the operation, to pass the night in his bed 
(perhaps for the first time in a long period), and to enable 
him to sleep a little, is a great gain." 

The general principles of safe treatment are summed up 
Dr. W. T. Gairdner as follows : — (i.) To make large allow- 
ance for the insignificant and spontaneously healing class of 
cases revealed more by physical signs than by symptoms, 
and to regard them as demanding little active treatment ; 
(2.) to consider rheumatic pericarditis in general as a disease 
susceptible, to a great extent, of cure under palliative local 
remedies and fitting constitutional treatment; (3.) to hold 
the general treatment as subordinate to the constitutional 
treatment of the disease with which the pericarditis is asso- 
ciated. 

Pericardium, Adherent. — Definition. — More or less 
adhesion of the opposed surfaces of the pericardium by in- 
flammatory exudation (adhesive lymph) becoming organized, 
and with more or less complete obliteration of the pericardial 
sac. 

Treatment must be regulated by the functional difficulties 
fc of the circulation, and by the source to which those difficul- 
ties may be traced. 

Pericardium, Dropsy of. — See Hydropericardium. 

Peritonitis. — Definition.-^- An inflammation of the serous 
membrane lining the cavity of the abdomen, and covering 
the viscera contained in that cavity. 

The Treatment of acute peritonitis must be active in pro- 
portion to the amount of pain, the rapidity of the pulse, and 
intensity of the inflammatory fever, which is marked by the 
peculiar depressing influence of the inflammation of the 
heart's action. In mild cases, when the pain is bearable, the 
pulse steady and under 100, twenty leeches over the abdo- 



285 PERITONITIS* 

men, followed by warm fomentations, with the administration 
of opium in frequently repeated grain doses, ought to be the 
basis of treatment. Leeches applied to the abdomen is the 
only method of blood-letting likely to be useful, and a poul- 
tice may be required afterwards to encourage the bleeding 
in sthenic cases. But where the disease is due to blood-poi- 
soning, constitutional states of ill-health, or to the puerperal 
state, blood-letting by leeches is injurious. In the severer 
forms the first indication is to relieve pain. The stomach 
may be unable to retain food ; and vomiting may be present. 
Under such circumstances great benefit may follow the in- 
jection per rectum of a pint of strong meat soup slowly 
thrown up in three successive portions. After about three 
hours' relief of pain, a fresh new injection of soup is to be 
given, when the same relief to pain will follow, the pulse 
falling from (say) 124 to 104. Small quantities of broth and 
wine may then be borne by the stomach, administered every 
two hours (Dr. Anstie). Action of the bowels should be 
prevented for several days. Opium should be given in doses 
of one to two grains, repeated as often as its effects subside 
— generally every two, three, or four hours. Morphia may 
be given in repeated doses of a quarter to half a grain. Mor- 
phia combined with chloroform, as in the formula for chloro- 
morphine or chlorodyne, will be found useful in allaying 
pain. It is not proven that calomel (inducing mercurialism) 
has any curative tendency in peritonitis. It has been pre- 
scribed traditionally ; but the experience of Dr. Taylor re- 
garding mercury in pericarditis, as well as of other physicians 
regarding the influence of mercury generally in the cure of 
these inflammations, tends to discard it from our methods of 
cure in such affections. Nevertheless, in the idiopathic and 
latent forms, Mr. Meade has found mercury the best remedy. 
In the purely latent forms he prescribes small doses of the 
bichloride with some demulcent. One-twentieth of a grain 
three times a day is sufficient. It may be continued for two 
or three weeks or more. In the more acute cases he directs 
the abdomen to be covered with dilute mercurial ointment 
spread thickly upon lint ; and he generally finds that the as- 
citic fluid begins to be absorbed as soon as the mercury 
slightly affects the system. Fomentations and water 
compresses are to be diligently employed on the same 
principle as described under Enteric Fever. Digitalis, with 
other diuretics, may assist the cure. In the more chronic 
forms, where the abdomen has become distended, it is some- 



PERITONITIS. 287 

times desirable to let off the fluid by tapping ; after which 
remedies' act more readily, and generally prevent the return 
of the effusion. Diuretics of iodide of potassium, acetate of 
potass, and squills, also help to effect the removal of fluid. 
The entire abdomen may be covered with cold compresses, 
and renewed every ten minutes ; but warm cataplasms are 
better borne than cold compresses by many patients (Nie- 
meyer). In chronic peritonitis I have found iodide of po- 
tassium, combined with alkalies, most useful, together with 
inunction of the abdomen with the iodine or biniodide of 
mercury ointment. Acute peritonitis has been treated by 
quinine alone, in large and repeated doses, by M. Beau, at 
the Hopital dela Charite. The remedy was given in the pro- 
portion of twenty to thirty grains in the twent-four hours. 
When the abdomen can bear pressure, a flannel roller should 
be firmly applied round the body. Chronic vomiting is a 
distressing concomitant to be met by effervescing draughts, 
with m j. or m ij. of dilute hydrocyanic acid, or with m iij. 
to m v. of tinct. opii. ; or one or two drops of creasote in 
aromatic water. Diarrhoea is common, hence it is necessary 
to combine any laxative remedy with an opiate ; and the 
bowels may be so irritable as to oblige us to abandon all 
opening medicine, and to prescribe astringents, as kino, ca- 
techu, or hsematoxylon, or the mistura cretae composita c. 
opio, or the acetate of lead, and even pure opium, to the 
amount of two, three, or four grains a day. Under any treat- 
ment diarrhoea is dangerous and distressing. The diet in 
the acute forms of peritonitis should be of the mildest and 
least stimulant kind. During the course of this and several 
other diseases of the digestive system, immense distress and 
suffering often occur from the accumulation and retention of 
gaseous fluid in some portions of the intestinal canal (tym- 
panites). Tympanites is best relieved by turpentine enema- 
ta ; and by the introduction of a rectum tube. When this 
symptom reaches such extreme development as to endanger 
life, and after the introduction of a rectum tube fails to pro- 
cure relief, experience justifies the propriety of making a 
puncture into the cavity of the bowel (generally the colon), 
through the abdominal parietes, to permit the gas to escape, 
and to relieve the tympanites. Life may thus be saved, and 
cannot be materially shortened by the operation, if it is per- 
formed by a trocar of the very smallest exploring size. The 
air gradually and rapidly escapes by the very smallest ori- 
fice, which is rather a separation of tissues than a wound, 



256 PERTUSSIS PHARYNGITIS, CHRONIC, ETC. 

and soon closes up so completely as to leave no trace behind. 
The operation gives the greatest possible relief (See Ameri- 
can Journal of Med. Science, N. S., XXIV., p. 543 ; Obstet. 
Trans., for 1869, pp. 47, 48, by Dr. J. Braxton Hicks, in 
1868 ; Brit. Med. Journal, for Oct. 21, 1871, p. 464, by Mr. 
J. Hancocke Wathen). The operation is not the same as 
that usually performed on cattle. In them it is generally 
the rumen or first stomach that is punctured (M'Bride in 
Brit. Med. Journal, Nov. 4, 1871). 

Pertussis — See Hooping Cough. 

Pharyngitis. — Definition. — Inflammation of the textures 
of the pharynx. 

Treatme?it should consist in hot steam inhalations of a 
sedative character, poultices externally, and scarification if 
oedema takes place. When the uvula is much swollen and 
infiltrated with serum, it should be at once removed. 

Sub-acute Pharyngitis may occur either as an early stage 
of the acute form, or as a less serious inflammatory affec- 
tion. In this condition it is the mucous membrane alone, 
not the areolar tissue, which is inflamed. The symptoms are 
less severe than in acute pharyngitis; and treatment consists 
in the application of astringent solutions, and the use of 
astringent lozenges. The frequent sucking of small pieces 
of ice is of great service in reducing the hyperasmic condi- 
tion. 

Pharyngitis, Chronic or Granular. — Treatment. — 
The patient's general health must be improved by tonic 
measures, but the most important part of the treatment con- 
sists in the persevering use of local applications. In the ex- 
udative form the spots should be scraped, the secretion emp- 
tied, and solid nitrate of silver applied to each diseased 
follicle. Lozenges of chlorate of potash and of bitartrate of 
potash are useful in stimulating the follicular secretion to a 
healthy condition. In hypertrophic pharyngitis the raised 
papules must be destroyed one by one. The best applica- 
tion for this purpose is a paste consisting of equal parts of 
caustic soda and unslaked lime; this is mixed with water, as 
required, into a creamy paste, and applied to each papule 
"vith a finely-pointed glass or aluminium rod (Dr. Morell- 
IVEackenzie). The caustic effect of this application is instan- 
taneous. The patient therefore should be directed to wash his 
mouth with water immediately after the application, so as to 



PHARYNX, ABSCESS OF PHTHISIS. 289 

prevent any other part of the throat being burnt by contact 
with the caustic. A combination of ergotine with tincture 
of iodine is also efficacious (ergotine, grains xx.; tinct. iod., 
f 3 i.; glycerine, to make f 3 i.) To be applied to the phar- 
ynx twice a day with a camel-hair brush 

In all cases of pharyngeal disease, every form of spice, 
pepper, mustard, and piquant food should be strictly pro- 
hibited, and all fluids should be taken at a moderate tem- 
perature. 

Pharynx, Abscess Of. — Definition. — Inflammation of 
the pharynx, resulting in a limited collection of pus in the 
form of an abscess. 

Treatment. — It is very rarely possible to prevent the form- 
ation of pus, and the expedient usually demanded is a speedy 
opening of the abscess at its most defending part. Cod- 
liver oil and other anti-strumous remedies are also impera- 
tively demanded. 

Pharynx and Larynx, Atomized Fluids in Treat- 
ment of — See Larynx, Pharynx &*c. 

Phlegmasia DoleilS. — Definition. — Obstruction of the 
veins, radicles, and capillary vessels, with probable implica- 
tion of the lymphatics, causing a painful, non-cedematous, 
hard brawny swelling of one or more extremities, attended 
with great prostration. 

Treatment. — Leeches and blood-letting, as recommended 
by Drs. Davie and Lee, are usually inadmissible. Sedatives 
and alkaline fomentations, perfect rest, simple diet, and opi- 
ates to relieve pain, is the most rational treatment to be fol- 
lowed. " The fluid in which the fomentation flannels are to 
be wrung out is made by adding one pound of bicarbonate 
of soda and one ounce of extract of poppies to one gallon of 
boiling water. The flannels ought to be changed every 
thirty minutes, and applied over the whole limb, and over 
the groin and lower part of the abdomen, wherever there is 
tenderness. The heat and steam from these are to be re- 
tained by means of impermeable cloths." Wine, brandy, 
milk, raw eggs, animal food, ammonia, and bark are sure to 
be required; and after the acute symptoms have subsided, 
there is no remedy so beneficial as efficient bandaging, to- 
gether with the preparations of iron, quinine, and tonic veg- 
19 



290 PHTHISIS. 

etable bitters, like calumba, aided by change of residence 
(Tanner). 

Phthisis. — Definition. — Lesions commencing with in- 
duration of a lobe or lobule of the lungs, ending in disinte- 
gration of the new material and of the textures involved in 
the induration; the formation of caverns, and the accumula- 
tion and constant discharge of purulent secretion, with or 
without the growth of miliary tubercles. 

Treatment. — Looking to the varied pathological conditions 
and textural lesions in the lungs comprehended under the 
name of phthisis, every case requires special study. In one 
case anaemia is prominent, and calls for iron, perhaps for 
arsenic; in another, continued but small haemoptysis may 
call for ergot; in another, a racking and frequent cough may 
call for special applications and remedies; in another, dys- 
pepsia may call for alkalies or acid bitters, or pepsine; in 
another, nervous unrest may call for bromides; in another, 
laryngeal troubles may call for special local medication; 
in another, we have to aim at controlling excessive sweating, 
or checking an exhausting diarrhoea (Dr. James Sawyer, 
Brit. Med. Journal, 1880, p. 845). 

If, unfortunately, a pulmonary catarrh does not abate, or 
a pneumonia does not resolve itself within the usual period, 
but catarrhal symptoms prevail in the apices, and pyrexia is 
persistent, with the severe disturbance of the general health 
which has been described, extension of the pneumonic pro- 
cess must be prevented by absolute rest in bed, talking being 
forbidden, and coughing as much as possible repressed. 
Whenever considerable pyrexia exists in the evening, all 
duty occupations should be given up, strict rest, equal tem- 
perature, the chest to be covered with linseed poultices, fre- 
quently repeated, or belladonna liniment, and local bleeding 
by leeches, if pleuritic pains exist. No counter-irritation 
should be applied to the seat of lesion while pyrexia lasts. 
Moderate action of the skin is to be maintained. The body 
should be sponged with rectified spirits of wine and hot 
water in equal parts (Coghill). White meats only are to be 
eaten ; and as much milk as may be desired. A pint of 
" warm milk from the cow " should be taken as often as 
possible. 

Should the pyrexia still continue, considerable digitalis, 
opium and quinine are the remedies most successful in re- 
ducing temperature. Heim's pill was much employed by 
Niemeyer, as it still is in Germany, for this purpose. It con- 



PHTHISIS. 29I 

sistsof Pulv. herb. Digitalis, gr. x.; Pulv. rad. Ipecac..; Pulv. 
Opii puri. a a, gr. v. ; Ext. Gentiani, q. s. ; misce et divide in pil. 
xx. One pill three times a day. It is of advantage that quinine 
to the extent of gr. xx. be added to this. Each pill will then 
contain half a grain of digitalis, one-quarter grain of opium, 
one-quarter grain of ipecacuanha, and one grain of quinine; 
all of which may be held in form by glycerine or syrup. Dr. 
Coghill adopts the following modification : namely, one 
quarter of a grain of opium ; half a grain of digitalis powder; 
and from one to three grains of quinine, to be given every 
three to six hours, watching the effect on the pulse. When 
there is great dryness of skin and tongue, half a drachm of 
salicine, and two drachms of liquor ammonia acetatis, may 
be given instead of the pill. Occasional intercurrent attacks 
of pneumonia mark extension of lesions. They are asthenic 
in character, and must be treated accordingly; but in all the 
sthenic pneumonias or acute bronchitic attacks, no remedy 
equals the tincture of aconite. It acts as we read of blood- 
letting doing. It should be given at the rate of one minim 
every quarter of an hour till the temperature is reduced to 
the normal — the thermometer being in use every two hours. 
If the temperature drops too suddenly, quinine must be 
given in place of aconite. 

The general principles of treatment described under 
"Scrofula," are to be adhered to. The use of so-called 
u cough-medicines," antimony, ipecacuanha, and squill 
especially, are to be avoided; also the use of mercury, pur- 
gatives, and neutral salts. It is unphysiological to administer 
narcotics or sedatives when cough is accompanied by expec- 
toration. The latter must be expectorated; if retained, it is 
injurious. The morbid surface which produces the expecto- 
ration must be directly acted on. In the suppurative expec- 
toration of bronchitis or pneumonia, and that from a pneu- 
monic or tubercular excavation of the lung, the processes 
are identical with the suppurative processes in surgical 
wounds or ulcers. Dr. Coghill finds that the best mode is 
to bathe the suppurative surface in an antiseptic atmosphere 
by the inhalation of such materials as creasote, carbolic acid, 
and thymol. Warm moist inhalations do not affect the res- 
piratory tract beyond the larynx; and are only of value in 
affections of that region. When used warm they increase 
the sensitiveness to cold. By using the breath only as the 
antiseptic medium (inhaling through the mouth and respir- 
ing through the nose), we get the whole of the residual air 



292 PHTHISIS. 

in the lungs saturated with the antiseptic material. This is 
the principle of Dr. Coghill's " respirator-inhaler," which 
should be used especially after " fits of expectoration," so 
as to act immediately on the surface which has furnished the 
matter expectorated. It cannot be used too often; and 
should quite supersede " cough-mixtures." It is, of course, 
only of use in the second and third stages of phthisis and 
the suppurative stage of bronchitis; and especially in the 
retained fetid expectoration of bronchiectasis. Dr. Cog- 
hill's standard formula (to be modified at discretion) for an 
antiseptic solution consists of one drachm of glycerine, one 
drachm and a half of creasote, two drachms of carbolic 
acid, and one ounce of a saturated solution of thymol: of 
which ten to fifteen minims are to be inhaled twice or thrice 
a day by the respirator-inhaler. A few drops of chloroform, 
or of ether, may be added as a sedative to each dose. In the 
first stage of phthisis and other conditions where there is 
cough and no expectoration, and in which the cough is inju- 
rious by shaking and shattering the tender and infiltrated 
lung tissue, the following is an excellent formula: — namely, 
Croton-chloral hydrate and codeia, a agr. xij.; AquaLauro- 
cerasi, glycerine, and Syrup of tolu. a a ad. 3 ij. A dessert- 
spoonful, or two teaspoonfuls, may be taken every two hours 
when cough is troublesome. 

To foster and cherish an appetite for food is another great 
aim of treatment. One of the best tonics, if pyrexia does not 
exist, is the syrup of iron, quinia, and strychnia. Let it be 
given in very small doses at first ; followed up by the use of 
cod-liver oil, " of the most agreeable, clearest, sweetest, and 
most scentless kind." The brown oil ought never to be pre- 
scribed, except, perhaps, to an Esquimaux. The oil should be 
given in teaspoonful doses at first. Dr. B. W. Foster, of Bir- 
mingham, drew the attention of the Profession to the advan- 
tages of ether in promoting the digestion and absorption of 
fatty food, and especially of cod-liver oil. A stomach once in- 
tolerant of all fat will good-naturedly accept full doses of cod- 
liver oil after the use of ether. Sometimes it has been given 
separately, before or after the oil; but it is best given com- 
bined with the oil — a mixture now generally known as 
" etherized cod-liver oil." To every two drachms of the oil 
ten, fifteen, or twenty minims of ether are to be added, 
according to the wants of the case. The JEther purus of 
the British Pharmacopoeia must be used, so that the oil 
may not be rendered muddy, as it will be if the ether 



PHTHISIS. 293 

contains alcohol or water. The ordinary dose of oil 
ought not to exceed two drachms, to which more than 
twenty drops of ether may be added, if necessary. The 
ether is indicated wherever there is inability to digest 
fat, of which it makes an emulsion. It seems to determine, 
when introduced into the stomach, a considerable flow of 
pancreatic juice (Claude Bernard; See Brit. Med. Journal, 
Nov. 21 and 28, 1868; also, Medical Press and Circular ; 
1869). Extract of malt (Trousseau) is a remedy of recent 
repute. It is a genuine extract, consisting of the soluble 
constituents of the malt and of the bitter extractive matter 
of the hop. Two or three table-spoonfuls of it are to be 
taken daily, diluted in spring water or in warm milk, or in 
any other liquid that may be desired. There should be a 
careful choice of meats and drinks. Meats rich in osma- 
zone and roasted are to be preferred; wines and malt liq- 
uors are better than mere alcoholic fluids when alcoholics 
are required. Broth made of coarsely brown rye' meal, 
beef, mutton, or other flesh meat, boiled to make a soup, is 
also of service as a diet. I have found the following soup 
also very serviceable: Take of linseed half an ounce; fine 
bran, one ounce; water, one quart. Boil these for two 
hours, and strain; then add beef, mutton, or any other meat 
that may be fancied, to the amount of one pound, and boil 
to a soup, with vegetables, to which celery seed or other fla- 
voring may be added. The whole quantity ought to be re- 
duced one-third. 

Arsenic is an efficient improver of the general nutritive 
and assimilative functions. One or two drops of Fowler's 
solution, or ^V of a grain of arsenious acid, should be given 
once, twice, or thrice a day, during the meal, continuing it 
for months, with occasional intermissions (Clymer). Decided 
benefit may follow the use of iodide of potassium, which may 
be combined with the ammonio-citrate of iron, or tincture of 
the muriate, in a bitter infusion with calumba or cascarilla. 
Chloride of calcium has been used for some years by Pro- 
fessor James Sawyer, of Birmingham, who writes very highly 
of its advantages in combination with cod-liver oil or its 
etherized emulsion. He gives 10 grains, dissolved in a 
drachm of water and with a drachm of glycerine, in a wine- 
glass of milk, twice a day, immediately after meals (Brit. 
Med. Journ., June 5, 1880). Dr. Coghill, from his exten- 
sive experience at the large hospital at Ventnor, regards the 
hypophosphites and lactophosphates alternately as the best 



294 PHTHISIS. 

general tonics in phthisis. They are in no way specific. 
They should not be given if the temperature in the evening 
is above 99. 4 Fahr., and, on account of their pyretic char- 
acter, should only be given after breakfast and lunch. The 
hypophosphite of iron is so powerfully pyretic as only to be 
given in extreme anaemic phthisis, where the whole daily 
thermometric range is low. Its formula consists of Hypo- 
phosph. Sodae, Hypophosph. Calcis, a a 3 i.; Glycerini vel 
Syr. Limonis, Jij.; Decoct. Cascarilla ad., §vj.; of which 
a table-spoonful in water may be taken as required, to which 
three to five minims of Liq. strychnine is a good addition to 
increase appetite. The pharmacopceal syr. of the lactophos- 
phates is very good; also the French " Dusart's." If an 
aperient is wanted it should be given early in the morning. 
Its necessity very often in phthisis depends on a sluggish 
liver, hence the following is a good formula : — Salicylatis 
Sodae, 3 ij. ; Phosph. Sodae, 3 v. ; Sulph. Potass, ad, | ij. ; 
Pulv. Zingib., 3 i- ; of which a teaspoonful in hot water is to 
be taken early in the morning. If there is an elongated 
uvula, the end should be snipped off ; if there is irritation 
about the pharynx and upper part of the larynx, it may be 
relieved by the inhalation of some of the atomized fluids. 

Counter-irritation to the chest-wall is a stereotype method 
of cure in local pulmonary congestions. When properly 
used in the earlier stages, before there is much loss of 
strength, it is undoubtedly beneficial ; but later it is weak- 
ening and annoying. Croton-oil liniment is the chief favor- 
ite ; but a prompt and not too severe application of the fol- 
lowing ointment is recommended by Dr. Fuller : 

IJ. Hydrarg. Chlor. Mit., gr. viij ; Iodinii, 3 ss. ; Alco- 
hol, f 3 iss. ; Unguent. Simp., 3 j. M. Rub in a portion over 
the affected lung, morning and evening, until a pustular 
eruption comes out 

A solution of the nitrate of silver (thirty grains to the 
ounce of distilled water) may be painted on the skin beneath 
the clavicles every evening until the skin is darkened, and re- 
peated after the cuticle peels off. Gentle and continuous 
irritation of the skin may be kept up by wearing constantly 
on the chest a piece of flannel wet with a weak solution of 
iodine in glycerine and water, covering the cloth with oil- 
skin, to prevent too rapid evaporation and soiling of the 
clothes. The night-sweats, so often annoying and profuse, 
diminish under general systemic improvement and restored 
cutaneous functions. The best anhydrotic, and almost the 



PHTHISIS. 295 

only one in use at the hospital at Ventnor, in the Isle of 
Wight, is a pill at bedtime, containing -gV of a grain of atro- 
pia, which may be combined with digitalis and quinine. 
Bathing with vinegar and water, spirits of wine and warm 
water, alum and water, are well-known remedies, as well as 
gallic and tannic acids, and infusion of common garden sage. 
To relieve the diarrhoea Dr. Coghill finds the lead and opium 
pill of the British Pharmacopoeia the best astringent, with a 
milk and arrrow-root diet. A flannel bandage around the 
abdomen should be worn. Bismuth, with opium, is also of 
use. To control the exhausting attacks which occur in the 
more advanced stages, Dr. Frank, at Cannes, suggested the 
use of coto bark ; and Dr. J. B. Burney Yeo (after an expe- 
rience of over three years) has found it to arrest the flux 
and relieve intestinal pain and irritation in a short time. A 
fluid extract of coto is prepared by Ferris & Co., of Bristol, 
the dose of which is from five to eight minims (The Practi- 
tioner, 1879, p. 257). 

As regards the prevention of phthisis, although Sir Thom- 
as Watson states that he does not believe it to be contagious, 
he adds : — " Nevertheless I should, for obvious reasons, dis- 
suade the occupation of the same bed, or even of the same 
sleeping apartment, by two persons one of whom was known 
to labor under pulmonary consumption " (Lectures on the 
Practice of Physic). It behooves the physician to warn the 
patient's friends of the dangers incident to long continued 
attendance on him, especially if the disease be in an advanced 
stage. It would be the height of imprudence for a healthy 
person, especially if young and of a scrofulous diathesis, to 
sleep in the same bed, or even in the same apartment, with a 
consumptive patient ; for although the malady might not be 
communicated directly from one to the other, unless possibly 
under the condition of some tubercular matter being acci- 
dentally introduced into his air-passages or into some other 
part of his system, the surroundings and the air would be cal- 
culated to predispose him to the disease " (Fuller, On Dis- 
eases of the Lungs and Air-passages, p. 431). 

It is of importance to know the physical nature of the cli- 
mates of the world suitable for the tuberculous patient. (See 
Appendix to a third edition of Dr. Walshe's work on Dis- 
eases of the Lungs ; the late Sir James Clark's classic work 
On Climate ; and Dr. Theodore Williams's Lettsomian Lec- 
tures in Brit. Med. Journ., 1876). Dr. Williams's statistics 
show the benefit to be derived from life at sea. In cases 



296 PITYRIASIS VERSICOLOR. 

where destructive lung diseases is suspected, but in which 
actual lesion does not exist, a sea voyage to the Cape, or to 
Australia, or to New Zealand, round Cape Horn should be 
resorted to at once. The prevention of certain forms of pul- 
monary phthisis may be looked for in the unrestricted enjoy- 
ment of pure out-of-door air. Continuous indoor labor is to 
be avoided, and measures taken to prevent bronchial ca- 
tarrhs by sufficient warm clothing and the constant use of 
flannel next the skin in this country. The effects of hydro- 
therapeutic treatment and of muscular exercise at the moun- 
tain sanitoria of Switzerland, along with the prescribed use 
of wine, fruit, and nutritious diet, are of much importance 
to be considered. The purity of the air of mountains con- 
sists practically in the absence of all organic particles. The 
transparency of the air, which is dependent on its greater dry- 
ness, and the more powerful action of light, depending upon 
the same cause, aid materially the operation of its purity. 
The effect of residence in mountains on the dimensions of 
the chest is also worthy of careful consideration, and has 
been studied by M. Armieux, at Bareges, at a height of more 
than 3,000 feet. He ascertained that in the case of ninety- 
six soldiers sent up to Bareges there was, after four months' 
residence, a distinct increase in the measurement of the chest 
— a fact which has a very important bearing on cases of 
threatened phthisis in the young ; and that a mountain cli- 
mate is to be considered as favorable to the development of 
the thoracic cavity, and consequently as improving the res- 
piration. (See also Dr. W. Marcet in Proceedings of R. S., 
Vol. XXVIII., p. 498). Mountain air may thus be useful in 
certain cases and in certain periods of phthisis. It acts by 
its purity, by its dryness and transparency, as well as by the 
diminution of atmospheric pressure. These principles have 
only, or nearly only, been applied in Switzerland ; but moun- 
tain stations for similar cases might very well be selected in 
some parts of France. After all, neither barometer nor ther- 
mometer, neither hygrometer nor anemometer, can determine 
what is the suitable climate for such and such a phthisical 
patient. All depends on the nature of his constitution, and 
on the way in which the various meteorological conditions 
affect him, and on the local lesions in his lung (Drs. J. Mac- 
pherson and Gouraud in London Medical Record, July 15, 
1876). 

Pityriasis Versicolor (see Tinea Versicolor). 






PLAGUE. 297 

Plague. — Definition. — A specific malignant fever which 
has prevailed at different times and places epidemically, at- 
tended with bubo or swellings of the inguinal and other 
lymphatic glands; or occasionally with carbuncles, pustules, 
spots, petechias of various colors, distributed in different 
parts of the body; and severe manifestations of implication 
of the nervous, sanguineous and bilious systems. 

Treatment. — It is to be regretted that recent experience 
has not in any degree advanced the successful treatment of 
the plague. In the beginning of the epidemic, when the 
morbid cause acts with a rapidity so great that some hours 
are sufficient to compromise the life of the patient, any 
treatment is powerless to arrest the course of the disease. 
When, however, the malignancy of the disease abates we 
may hope for the recovery of patients (Clot Bey). Looking, 
however, to the pathology of the disease, and regarding it as 
bearing some resemblance to malignant typhus fever, the 
principles of the general treatment of plague ought to be 
similar to those laid down in the account of that disease. 
We have no sufficient evidence to prove that plague may be 
carried beyond those geographical limits where it is epi- 
demic. Quarantine establishments to prevent the trans- 
mission of such epidemic diseases are now not only unwar- 
rantable, but they are vexatious interruptions to mercantile 
enterprise. It is now more than 154 years since any part of 
Western Europe has suffered from plague; but till a com- 
para'ively recent period, more or less of the disease had been 
habituate or frequent in the Levant, and though occasions 
have been very numerous when arrivals from the Levant in 
this country must have been more full of danger than those 
now represented, the experiments thus performed on the 
public health of England have in no case led to any injur- 
ious result. I am informed by a medical friend who visited 
Malta in 1861, that a curious instance of the wavering 
nature of opinion regarding the efficacy of quarantine was 
afforded during the last Bengazi plague. The Maltese — 
the most sensitive people formerly on the subject — abso- 
lutely declined to put any quarantine on arrivals from Ben- 
gazi, and trade went on as usual, until the Austrians inti- 
mated that, unless Malta put Bengazi in quarantine, Trieste 
would put Malta in quarantine; and the poor merchants were 
obliged to submit. There is little risk of plague being im- 
ported now because of the great sanitary improvements 
which have taken place; and it is to be hoped that as sani- 



290 PLEURISY. 

tary measures are developed the barbarism of quarantine will 
entirely disappear; except, perhaps, where the intelligence of 
the people does not go beyond that of the Russian Governor 
of Eupotoria, who requested that the allied armies of France 
and England might go into quarantine when they landed in 
the Crimea in 1854 ! (Kinglake.) 

Pleurisy. — Definition. — Inflammation of the serous mem- 
brane that lines the cavity and covers the viscera of the 
thorax. It is characterized at its outset by febrile chills, 
followed by an acute sharp pain in some part of the chest, 
frequently called " a stitch in the side." It is usually con- 
fined to one spot about the lateral regions of the thorax. 
The acts of respiration are performed rapidly. They are 
shallow, irregular, and incomplete. A dry short cough 
supervenes, and the pulse is hard and quick. The natural 
serous secretion of the pleural sac is arrested in the first in- 
stance, but soon becomes increased in quantity and altered 
in quality, having a tendency to assume the corpuscular 
character. The effusion may rapidly increase, and may ulti- 
mately assume a sero-purulent character, the parietes of the 
corresponding side of the chest being dilated accordingly. 

Treatment. — In acute pleurisy venesection can be dis- 
pensed with. It neither cuts short the malady nor prevents 
effusion. It may only be adopted in cases of severe dyspnoea, 
arising from collateral hyperemia, if the compressed part of 
the lung is attended with signs of oedema. At the com- 
mencement of less severe cases the use of cold compresses, 
and of local blood-letting by leeches or cupping, may be re- 
peated in the course of a day or two, until relief becomes 
permanent ; but the local blood-letting is only to be had re- 
course to if the cold compresses do not relieve the pain and 
the dyspnoea within two or three hours. Large hot poultices 
of linseed with mustard should be always employed when 
local pain on inspiration is present of a " catching" or "stab- 
bing" nature. If the pain and dyspnoea are not relieved 
within two or three hours, the method originally recom- 
mended by Dr. Frederick T. Roberts, in his " Handbook of 
Medicine " (page 508), of mechanically fixing the side 
affected, so as to prevent its movements as much as possible, 
ought to be at once adopted. " Strips of properly adherent 
plaster, spread on a firm material, are cut about four inches 
wide, and sufficiently long to extend round the side from 
mid-spine to mid-sternum, or a little beyond. These are laid 
over a variable extent of the chest, according to the severity 



PLEURISY. 299 

of the case, it being sometimes requisite to include the whole 
side — beginning below. The patient is directed to EX-pt're 
deeply, and at this time a strip of plaster is fixed at mid- 
spine, and drawn tightly round the side in the direction of 
the ribs ; then another strip is laid over this, but across the 
course of the ribs ; the third follows the direction of the first, 
overlapping about half its width ; the fourth that of the 
second, and so on in alternate directions. A strip may also 
be passed over the shoulder, and kept down by another fixed 
round the side across its ends." Tartar emetic subdues the 
inflammatory tendency. Its use must be abandoned as soon 
as the acute symptoms have passed away. Digitalis, rather 
than tartar-emetic, may be given in recent cases in the form 
of infusion. In the more latent cases one grain of the pow- 
der of the leaves may be combined with a grain of quinine. 
Blisters are not to be used until the acute stage is past. 
When pain has ceased for some days, and absorption of the 
fluid proceeds slowly, and the disease promises to become 
chronic, a succession of blisters may be of use, applied over 
the lateral region of the chest, but not over the seat of pain. 
Diuretics ought at the same time to be freely given. The 
compound tincture of iodine, in doses of twenty minims 
freely diluted, is a valuable medicine at this juncture ; and 
so also is the liquor iodi of the "British Pharmacopoeia" of 
1867. After free evacuation of the bowels has been effected, 
calomel, to the extent of producing the slightest mercurializa- 
tion, is the most beneficial line of treatment, to be adopted 
in certain cases only — namely, in otherwise healthy persons 
in whom the pleurisy is not the result of a constitutional dis- 
ease. The more rapidly slight mercurialization can be pro- 
duced the better. During the first six hours, small doses of 
calomel with opium (a grain and a half of the former, com- 
bined with a sixth of a grain of the latter, or more, if the 
pain continues acute) should be given every half hour, while 
mercurial ointment is rubbed into the skin of the affected 
side near the axilla every fourth hour (Walshe) ; or half 
grain or grain doses of opium, every three or four hours, in 
combination with one or two grains of calomel, and half a 
grain of digitalis, may be given, and the whole side may be 
covered with a piece of linen spread with mercurial oint- 
ment : over this is placed a poultice covered with oiled 
silk. The patient must be- carefully watched, so that 
neither ptyalism nor narcotism is produced. The moment 
mercurial action has been established, the further admin- 



300 PLEURISY. 

administration of the mineral must cease. Opium and digi- 
talis are to be continued after the use of calomel has been 
suspended ; and with them may be given two grains of 
squills Or of nitrate of potash, as a diuretic ; or after twelve 
or more hours very small quantities of tartar emetic in solu- 
tion maybe given at night, combined with small doses of 
opium and ipecacuanha, to allay general irritation. 

In the chronic stage of pleurisy there is a necessity for 
generous diet and tonic remedies, such as quinine, in aid of 
any diuretics and absorbents which may be employed. If the 
patient be kept too low after the stage of active inflammation 
has subsided, or be unduly depressed, it will not only be im- 
possible to induce absorption, but there will be great danger 
of the fluid becoming se'ro-purulent. When a succession of 
blisters has failed in relieving the patient, ioduretted lotions, 
or ioduretted ointments, combined with the internal admin- 
istration of cinchona with tincture of iodine, iodide of potas- 
sium, and small doses of bichloride of mercury, nitre, acetate 
of potash, squills, digitalis, and cantharides, have each in 
their turn effected the desired object (Fuller). The 
fluid has been gradually reabsorbed, and recovery has en- 
sued by a combination of iodine remedies, taken internally, 
and applied externally — e. g., syrup of the iodide of iron 
( 3 ii.)> with simple syrup ( 3 ii.), and a teaspoonful taken 
every two hours, in conjunction with the external application 
of a weak solution of iodine (iodine, 3ss.; potass, iodidi, 
3 ii- ; aq. distil., % ii.) upon the affected side of the chest 
(Niemeyer). Other formulae most useful in such cases are — 
(1.) A diuretic in the form of a pill, composed of digitalis, 
squills, and the mass of pill, hydrargyri, of each a grain and 
a half. Nitrate of potash (twenty grains), combined with 
tincture of the perchloride of iron (fifteen minims), three 
times a day, may at the same time be given (Fuller, Cham- 
bers). Professor W. T. Gairdner recommends as a diuretic 
the cream of tartar electuary, in which the cream of tartar is 
mixed in equal proportions with treacle, honey, marmalade, 
or syrup of ginger, and in some cases flavored with a few 
drops of peppermint oil. The dose is a teaspoonful, re- 
peated as often as the stomach will bear it, or as the urgency 
of the case demands. Jaborandi, in the form of infusion, 
has recently been advocated in the treatment of chronic 
pleurisy with serous effusion. (2.) A lotion, to be applied 
over the chest by spongeopiline, or by lint covered with oiled 
bilk, composed of — Bichloride of mercury, gr. iv. ; tincture 



PLEURISY. 30I 

of iodine (compound), 3 iv. to 3vL; glycerine, 3 iil. ; and 
distilled water, 3 ivss. (3.) One or other of the following 
ointments may also be rubbed upon the skin, over the side 
of the chest — Bichloride of mercury, gr. iv. to vi.; iodine 
ointment, 3 iv. to 3vi.; lard, or vaseline, % iv. to |vi.; or, 
bichloride of mercury, gr. iv. to v.; iodine of potassium, 3 ii. ; 
distilled water sufficient for solution ; and lard, or vaseline, 
3 i.; Ft. Ung. Feeding the patient upon the driest possible 
diet, and withholding water as much as possible, has been 
successful in some cases (Schroth). 

As a means of relieving the chest in chronic pleurisy and 
empyema, the operation of puncturing the chest and letting 
out the fluid — an operation to which the name of paracente- 
sis has been given — is a useful one ; and the practical ques- 
tion is as to the time when it should be performed. The con- 
dition of the patient's health and respiration, and the absorp- 
tion or non-absorption of the effused fluid, are the aids to a 
decision for or against its performance. As long as the 
breathing is not seriously embarrassed, and the general health 
does not decline, so long are we justified in making full trial 
of our remedies. But as soon as extreme shortness and dis- 
tress of breathing, or lividity and anxiety of the countenance, 
denotes serious interference with the functions of life, delay 
is no longer justifiable, and it becomes our duty at once to 
give our patient the chance which the operation affords. In 
the hands of the American physician, Dr. Bowditch, and 
Professor W. T. Gairdner, of Glasgow, and Dr. Budd, of 
London, this operation has been the means of saving many 
lives. Its effect is to relieve the mind as well as the lungs 
of the patient from great oppression. Although before the 
operation he may be quite weak, he is often able after it to 
get up and walk. Digestion becomes at once improved, and 
strength is rapidly regained. The cough, however, is apt to 
augment during the first few days ; the pulse retains its quick- 
ness ; friction-sounds occasionally become developed, and 
several months may elapse before the vesicular murmur be- 
comes properly re-established in the lung. Generally, the 
operation of paracentesis thoracis in simple pleurisy is not to 
be performed unless the life of the patient is in ieopardy — 
that is, in cases " in which the effusion continues and in- 
creases, and the side, instead of shrinking, enlarges : the 
functions of the lung on that side are entirely abolished; nay, 
the use of the remaining lung is greatly interfered with by 
the pushing over of the mediastinum ; and the patient is in 



302 PLEURISY. 

imminent danger of suffocation." In such cases the oppressed 
lung must be relieved by " letting the fluid out " (Sir Thomas 
Watson, Lectures, Fourth Edition, Vol. II., p. 128). " Life 
is plainly in jeopardy when the vital functions of the lungs 
or of the heart are greatly hindered ; when symptoms pre- 
sent themselves of approaching death by apncea or by syn- 
cope. If we discover no cause for those symptoms except 
the increasing pressure of liquid pent up in the pleura, we 
are warranted in ascribing them to such pressure, and bound 
to act upon that persuasion." Also, if death by asthenia ap- 
pears inevitable, the patient losing ground from day to day, 
and when all other means of getting rid of the pent up fluid 
have failed, the patient should not be denied the chance 
which the operation affords. Also, " whenever the effused 
liquid consists of pus, it should be let out" (1. c, p. 130). 
The risks of allowing a localized empyema to remain are 
great (Wilks). With the arrangements of Dr. Bowditch's 
syringe we are enabled to remove fluid before the false mem- 
brane thickens over the compressed lung, and so makes it 
difficult to expand again. The trocar and small canula take 
the place of an exploring needle. Therefore, if the lungs are 
not "bound down by adhesion, or prevented from expanding 
by the thickness of the false membrane which covers it, 
Bowditch's syringe and stopcocks enable the fluid, even when 
purulent, to be withdrawn without air being admitted. Mr. 
Lister's antiseptic method and precautions as to opening an 
abscess ought to be adopted. But when air has been admit- 
ted, and when the fluid within the cavity of the chest has be- 
come changed thereby — is purulent and perhaps fetid — the 
evacuation, under antiseptic precautions, of the contents by 
"drainage" seems the most efficient remedy. 

In Pneumothorax. — Puncturing the chest walls may give 
temporary relief, by allowing the air to escape ; but the op- 
eration ought only to be done in cases where the dyspnoea is 
urgent, and the displacement of the viscera such as demands 
that relief which the operation is calculated to give. Other- 
wise, the treatment of pneumothorax is best conducted by 
small doses of morphia — /. <?., stimulant doses — frequently 
repeated, combined or not with ether or alcohol, with a view 
to overcome collapse, relieve dyspnoea, and subdue pain. 
When reaction follows collapse, as indicated by heat of skin, 
strength and hardness of pulse, soreness and pain of the af- 
fected side, local blood-letting by leeches, with saline aperi- 
ents, may be used if the strength of the patient warrants such 



PNEUMONIA. 303 

a line of treatment. Turpentine and poppy fomentations, 
followed by blisters, are also indicated if life is sufficiently 
prolonged after the primary inflammatory symptoms are sub- 
dued. The inhalation of small quantities of chloroform is 
useful. In other respects the treatment is similar to that al- 
ready stated. 

Pneumonia. — Definition. — Inflammation of the lungs, 
which, in its acute sthenic form, is often complicated by con- 
stitutional or specific diseases. It runs a definite course, 
expressed by severe febrile symptoms, which come on sud- 
denly, attaining in a few hours a great intensity, but which 
may undergo a no less sudden abatement or improvement 
between the fifth and tenth day, in proportion to the severity 
of the disease and the textures implicated, while the local 
productive results of inflammation in the form of the lung- 
lesion are yet intense, but which are eventually removed. 
The natural course of pneumonia is materially modified by 
constitutional or specific diseases, especially if any organ, 
such as the kidney, the heart, or the liver, is involved ; or it 
may be modified by the secondary contamination of the 
blood by absorption of lung-exudation in the later stages of 
the disease, tending to inflammation of the other lung, to 
pleurisy, to pericarditis, or to blood-coagula in the cavities 
of the heart or great vessels 

Treatment. — One of the most discordant topics in the Sci- 
ence of Medicine seems still to be with some — the treatment 
of pneumonia. At one time (about fifty years ago) large 
bleedings were the rule. But Laennec and Louis were early 
convinced that large bleedings were by no means successful, 
and that in some cases they were absolutely injurious. The 
some difference of opinion was held with respect to large 
doses of the tartrate of antimony. At the same time we have 
it in our power materially to modify the course and to short- 
en the duration of pneumonia by the judicious employment 
of blood-letting, leeches, tartar emetic, certain salines, and 
opium (Parkes). The correlation of the body-temperature 
the number of the pulse, and the respirations per minute, 
furnish the best guide as to the course to be pursued in the 
treatment of pneumonia. If the pneumonia is not intercur- 
rent to some other disease, but happens idiopathically in a 
person otherwise healthy ; if the mean body-temperature re- 
mains below 104 Fahr., the pulse does not exceed 120 beats 
in the minute ; and if the respirations never exceed forty in 



304 PNEUMONIA. 

the same time, the case must be regarded as a typically fa- 
vorable case, which will certainly begin to get well when the 
cycle of the pneumonic process is complete — i. e., in from 
three, four, seven or eight, to twelve days without any special 
medicinal treatment ; but with the careful management im- 
plied by good nursing, absolute rest in the horizontal posi- 
tion, and a strictly antiphlogistic diet. In such cases it is 
sufficient to keep the patient in bed, in a well ventilated room, 
whose temperature should be kept as near 60 ° Fahr. as pos- 
sible, to relieve thoracic pains by leeches, or fomentations, 
linseed and mustard poultices ; to relieve thirst by alkaline 
or acidulated drinks ; and to give frequently repeated small 
quantities of nutritious fluid food in the form of milk, milk 
and eggs, oatmeal gruel, or even meat soups. The natural 
history of an uncomplicated pneumonia shows that it has a 
definite cyclical course; that if left to itself in a vigorous pa- 
tient, uncomplicated by any other ailment, and if it be of the 
typical intensity as here indicated, it almost always ends in 
recovery. The expectant mode of treatment of the Vienna 
school confirms this view, as the statistics collected by Bal- 
four, Magendie, Skoda, Niemeyer, Schmidt, and Legendre 
fully prove. In cases of average severity there is a decided 
tendency to amelioration of all the symptoms by the eighth 
day. The results obtained by the Homoeopaths have also 
shown this to be the case. Unless warranted, by certain 
special indications, active interference has an unfavorable 
effect upon the course of pneumonia (Niemeyer) ; and when 
treated by blood-letting, as a rule, it more often terminates 
fatally than where no venesection has been practiced (Diett). 
Blood-letting is no specific. It does not cut short a pneumo- 
nia ; and in epidemic pneumonia it is hardly possible to 
bleed the patient without rendering him worse. But much 
must be left to the discretion of the practitioner. That there 
are cases in which the patient can only be saved by general 
blood-letting, everybody must admit. The cases of Louis and 
of Dr. Alison of Edinburgh establish the propriety of bleed- 
ing early, if blood-letting is to be used at all. As a general 
rule, the earlier the inflammatory state is detected (if possi- 
ble before the third day — Alison) the more likely will bleed- 
ing be followed by well-marked beneficial results, the disease 
will be sooner cured, and the convalescence more rapid and 
perfect. Blood-letting in pneumonia should only be had re- 
course to when the following special indications for it arise : 
— (1.) When the pneumonia attacks a vigorous and hitherto 



PNEUMONIA. 305 

healthy person, is of recent occurrence (not exceeding fifty 
or sixty hours after the rigor), the temperature being at or 
exceeding 105° Fahr., and the frequency of the pulse as much 
as 120 per minute. The object of such venesection is to re- 
duce temperature, lessen the frequency of the pulse, and so 
lessen the danger from the violence of the fever. (2.) When 
collateral oedema in the portions of the lung unaffected by 
pneumonia is causing danger to life, the presence of the 
blood is reduced by bleeding, and further transudation 
of serum into the air-vesicles is prevented. When the 
frequency of respiration is due to the pneumonic pro- 
cess alone — not to fever or to' pain — -and as soon as a se- 
rous foamy expectoration appears, together with a respiration 
of more than forty or fifty breaths a minute at the com- 
mencement of pneumonia ; and when the rattles in the chest 
do not cease for a time, after the patient has coughed as 
well as he can, copious blood-letting is indicated to reduce 
the mass of blood, and to moderate collateral pressure. (3). 
When there are symptoms of cerebral pressure indicated by 
stupor or transient paralysis. 

Antimony, in the form of tartar emetic, is another remedy 
which has gone through several extremes of administration 
in the treatment of pneumonia. Rasori introduced the prac- 
tice of giving it in large doses, and Laennec was so dissatis- 
fied with his own results of bleeding that he adopted Rasori's 
method. Few, if any, now believe in the usefulness of such 
large doses of antimony; and such a use of tartar emetic has 
justly fallen into discredit. When antimony is cautiously 
administered as a sedative, or diaphoretic and expectorant, 
in doses of the eighth or twelfth of a grain, every two or three 
hours, and in doses of a sixth or a quarter of a grain, in the 
more sthenic attacks, when the patient is strong and plethoric, 
it is a valuable remedy. It niay be combined with compound 
tincture of camphor, or dilute hydrocyanic acid. It is contra- 
indicated in gastric or gastro-enteric irritation. There are 
cases where the remedy produces severe depression and 
nausea — cases in which the stomach will retain no food, not 
even water when given alone. Under such circumstances 
the administration of alcohol in stimulant doses often re- 
peated is called for, and may require to be combined with 
ammonia, chloric ether, and camphor. Alcohol is especially 
indicated by the occurrence of delirium (if vascular excite- 
ment does not exist); by a weak, rapid, or dicrotic pulse; by 
signs of collapse; by age and general debility of the patient; 
20 



306 PNEUMONIA. 

or in cases of pneumonia secondary to those diseases which 
it frequently complicates. 

A rational treatment of pneumonia is one which must 
secure to each case its own individuality and consideration. 
Bleeding, antimony, and blisters may be demanded in one 
case ; quinine, opium, and wine In the next ; a third may 
require but little interference beyond a well-regulated diet, 
moderate stimulants, and absolute rest. It is the proper 
combination of remedies, not a single agent or mode of prac- 
tice, which must be sought for in its treatment (Lawson). 
The so-called "rational" or " restorative " mode of treat- 
ment is the one to be adopted in cases of sthenic pneumonia 
characterized by heat, above 104 Fahr., dryness of the skin, 
a full resistant pulse, over 120, rusty-colored expectoration, 
great oppression of the breathing, and to the extent of 
beyond forty respirations per minute, blood-letting, had re- 
course to at the beginning of the attack, in the stage of con- 
gestion before the fastigium of the pyrexia (not later than 
forty or fifty hours after the initial rigor), not only affords 
immediate relief to the breathing, but removes the extreme 
tension of the vascular system, and promotes secretion. The 
most suitable time is that during the evening exacerbation 
(Huss). These indications for blood-letting should be de- 
cidedly marked before it is undertaken ; and the amount of 
blood to be lost varies in each case, according to the oppres- 
sion of breathing, the type of the disorder, and the constitu- 
tion of the patient ; as well as to whether or not there is any 
prevalent epidemic tendency associated with the pneumonia. 
It is seldom necessary to draw more than from ten to sixteen 
ounces ; and eight or ten ounces will usually suffice. After 
bleeding, the pain in many instances ceases, expectoration 
takes place more easily, and alters in character ; the skin be- 
comes moister, and evidence is afforded of the action of 
remedies which before proved inoperative (Fuller). But in 
many cases it is either unnecessary or inexpedient to let 
blood — inexpedient chiefly because of the constitution of the 
patient being shattered by excesses, constitutional disease, 
anxiety, and mental distress. Under such circumstances, it 
impairs the strength, leads to greater impoverishment of 
blood, arrests the actions on which the absorption of exuda- 
tion-matter depends, and induces a tardy convalescence. 
Bleeding ought not to be employed after extensive consoli- 
dation of the lung has taken place. 

The cases in which tartar emetic, in small doses (one- 



PNEUMONIA. 307 

eighth of a grain) fails to exercise a curative action are those 
in which hepatization proceeds with extreme rapidity; in 
which crepitation either does not exist at all, or is of very 
short duration, giving place after a few hours to intense 
tubular breathing ; and those which are marked by extreme 
depression almost from the first. Salines and stimulants with 
opium, if necessary, are found to be the most efficient means 
of treatment in such cases. Of other proposed remedies, the 
following may be noticed, namely: — (1.) Aconite is only to 
be given at the very outset, or first stage of pneumonia, from 
miii. to mv. of the tincture of B. Ph. every four hours (Wilks); 
or from mii. to miii. every three hours at the outset of the 
congestive stage (Keith, £din. Med. Journ., Oct., 1868, p. 905.) 
Half a drop to one drop of the tincture in a teaspoonful of 
water every ten or fifteen minutes for two hours, and after- 
wards to be continued every hour, has been useful in febrile 
catarrh and catarrhal croup, and may be useful in some of 
the phases of pneumonia, especially to subdue increased 
action of the heart and circulation, and to reduce the abnor- 
mally high temperature. Care must be taken that the remedy 
is not combined with alkalies (Ringer). (2.) Carbonate of 
ammonia. — A combination of ammonia and chloroform 
(where antimony in small doses is not indicated) may be 
taken every three or four hours. Four grains of carbonate 
of ammonia, twenty minims of the spirits of chloroform, in 
five drachms of camphor water, combine the beneficial 
properties of both stimulants (Waters). It is indicated when 
the symptoms generally resemble those of delirium tremens, 
when the pulse is small and weak and quick, or if delirium is 
present. (3.) Digitalis has of late years been employed by 
Oppolzer, Traube, Schneider, Niemeyer, and others, as one 
of the best agents for the relief of the febrile symptoms. It 
lowers the temperature and diminishes the frequency of the 
pulse, without exercising so weakening and depressing an 
effect upon the system as bleeding. A pulse of 100 to 120 
in frequency is an indication for its employment — a less fre- 
quent pulse does not require it. It is usual to give it in the 
form of infusion, combined with the neutral salts of nitrate 
of potass and soda. Digitalis may be advantageously 
combined with ergot, in the proportion of four drachms 
of the fluid extract of ergot to one drachm of digitalis, with 
six grains of the acetate of lead in two ounces of cinnamon 
water, of which a tablespoonful is to be given every two 
hours till the blood disappears from the sputa (Wells, 



308 PNEUMONIA. 

New York Med. Record, Vol. XV., No. 17). (4.) Opium is 
of great service. It may relieve the pain of the side, and 
diminish the distressing cough. It is also of use in warding 
off delirium, combined with stimulants and nourishment. It 
ought to be given when there is want of sleep, restlessness, 
and staring of the eyes, with slight tremors of the hands. It 
may be used hypodermically. (5.) Hydrochlorate of am- 
monia is of use in congestion of the lungs, in the advanced 
stages of pneumonia, and in the cough of old age. One 
drachm is to be combined with one drachm of extract of 
liquorice; two drachms of spirit of sulphuric ether, and four 
ounces of water, of which a tablespoonful is to be given for 
a dose every two or three hours (Waring). Or it may be 
given in one or two grain doses every hour or two, mixed 
with equal parts of glycerine and water. (6.) Iodide of 
potassium, in the advanced stages of pneumonia, appears to 
promote the absorption of effusions and indurations. In 
severe cases of broncho-pneumonia, combined with tincture 
of hyoscyamus and ammonia it may reduce the frequency of 
the respiration in a marked degree. (7.) Quinine is of use 
chiefly in the advanced stages when the patient is old, the 
constitution debilitated, and typhoid symptoms prevail. It 
is best given in combination with sulphuric acid, in doses of 
five grains every third hour. The pulse ought to become 
slower and steadier under its use, and the respiration freer. 
It should be given in .doses of two grains every two hours, or 
in two or three ten grain doses within a few hours, whenever 
danger threatens from excessive elevation of the tempera- 
ture of the body. (8.) Alkalies. — Bicarbonate of potash, 
largely diluted in mucilaginous liquids, five grains up to 
thirty grains in each dose, — four, six, or even eight doses 
being given in the twenty-four hours to the extent of two to 
three drachms of the salt per day), alters the character of the 
expectoration by the second or third day of its use. The 
viscid sputa become resolved; the fine bubbles become 
coarse and large; the red color of the expectoration disap- 
pears; its tenacity of adhesion lessens, so that it is brought 
up easily, and the cough becomes moist, soft, and expulsive. 
Thus the alkali acts as a sedative, allaying the cough and 
abating the congestive state on which it depends. The 
white pasty fur over the tongue dissolves away in an in- 
creased flow of saliva. The urine becomes alkaline, and the 
physical signs of pneumonia become resolved. It has also 
a marked action as a nerve sedative. A drachm dose in 



PNEUMONIA. 309 

water produces an agreeable, tingling, numbing sensation, in 
the lips, cheeks, and other parts, extending gradually to the 
lower limbs. It is especially indicated where the pneumonia 
is associated with rheumatism. " Flying blisters," applied 
for four or six hours, so as to redden the skin (not for sup- 
puration), is a valuable auxiliary. Suppuration from blister- 
ing is to be avoided as exhaustive and prejudicial (Dr. John 
Popham, Brit. Med. Journ., Dec. 28, 1867, p. 586). (9.) 
Stimulants. — The treatment by repeated alcoholic stimulants 
alone is but the opposite extreme of practice to excessive 
blood-letting. It has now found its level and appropriate 
place as a valuable aid to other remedies, especially in pa- 
tients whose constitutions are depressed under the influence 
of life imposed upon them by the " great town system." 
When pneumonia tends to death by exhaustion, as the dis- 
ease advances; when exudation lias been excessive, the 
fever prolonged, or the constitution debilitated before the 
attack, such a state of complete adynamia requires the use 
of stimulants, in the form of large doses of camphor, mint, 
benzoic acid, alcoholic drinks; and in addition, concen- 
trated soups and milk are called for in small quantities, 
given often. In old persons, stimulants, with generous diet, 
preparations of quinine and iron, are indicated from the very 
commencement. Alcoholic stimulants are rarely required in 
young persons, or in previously healthy adults. 

Some local applications require special notice, namely : — 
(1.) Cold Applications. — The chest of the patient (the af- 
fected side in particular) is to be covered with cloths that 
have been dipped in cold water and well wrung out. Com- 
presses thus made must be repeated every five minutes. 
After a few hours the patients experience a material relief. 
The pain, dyspnoea, and frequency of the pulse are reduced, 
and the body-temperature may go down an entire degree 
(Niemeyer, Smoler). The treatment is not merely palliative, 
but tends to shorten the duration of the illness. Few cases 
delay to improve beyond the seventh day, many improve 
on the fifth, and a very large number as early as the third 
day. The remedy is justly held in repute for meningitis and 
peritonitis, and hence it may fairly claim to have a similar 
good effect in pneumonia. 

(2) Linseed Meal Poultices. — On the other hand, heat com- 
bined with moisture in this form, made as light and soft as 
possible, and sufficiently large as thoroughly to inclose the 
affected side, and changed as often as it gets unpleasant, not 



3IO PODAGRA — PORRIGO FAVOSA. 

only affords present relief, but exercises a favorable influence 
on the course of the disease. The skin may be at the same 
time stimulated by mustard, or terebinthine applications, 
added to the poultice. 

(3.) Turpentine. — Hot turpentine fomentations may be ap- 
plied over the affected side also with advantage. 

(4.) In children it is sometimes of importance to be able 
to induce cough and expectoration. This can be facilitated 
by using a spray of a weak warm solution of carbonate of 
soda, to which a little glycerine of carbolic acid is added. 
It is a valuable resource in promoting the expulsion of the 
plugs of tough mucus which tend to accumulate in the bron- 
chial tubes of children with bronchopneumonia (Dr. Burney 
Yeo, Brit. Med. Journ., Dec. 7, 1878). 

Time is an important element in the cure. As particular 
phases in the course of the pneumonic cycle call for special 
treatment, so much more successful will the management of 
the case be if the indications for interference are understood 
and acted upon. The natural course of the disease is to go 
on rapidly to a spontaneous favorable termination, by a pro- 
cess of resolution through which the solidified lung-tissue 
regains its natural and healthy state, independently of rem- 
edies. Those remedies that have been specially noticed may 
each be of service in safely and surely controlling the circu- 
lation when the indications for treatment are short of requir- 
ing the agency of blood-letting. Their effects must be 
watched so that they do not lower the vital powers nor dis- 
turb the digestive functions. The indications for nourish- 
ment, properly adjusted to the circumstances of each case, 
and each stage of the case, are of paramount importance 
from the first; and the happy issue of a case of pneumonia 
depends quite as much upon early and properly feeding the 
patient as a case of typhus or enteric fever does. A milk 
diet should be given from the commencement, to be followed 
by beef-tea and meat-stock soups as the disease advances 
and the pulse softens. Stimulants cannot be regarded as the 
equivalent of food (Clymer). 

Podagra — See Gout. 

Pompholox — See Pemphigus. 

PorrigO Decalvans— See Tinea Decalvans. 

PorrigO Favosa — See Tinea Favosa. 



PSORIASIS. 31I 

Psoriasis. — Definition — An eruption characterized by the 
development of irregularly formed patches of a dusky red or 
coppery hue, slightly raised above the level of the skin, and 
covered with thin, dry, white scales. 

Treatment. — Preparations of arsenic are found to be of 
great service in this squamous form of eczematous inflamma- 
tion. A form of arsenical remedy, known as the Asiatic pill, 
is recommended by Cazenave. Its composition is as follows : 

3 Arsenici Protoxidi, gr. i. ; Pip. Nig., gr. xii.; Pulv. Acac, 
gr. ii.; Aq. Distill, q. s. — Divide in pil. xii. vel. xvi. One 
pill to be taken once, twice, or thrice daily after meals. 

It is of the greatest importance that the meals and the diet 
should be regulated. Small doses of pilulae hydrargyri, or 
of pilulae calomelanos composita, or hydrargyrac. creta, may 
be given at bedtime for a few days, followed each morning 
by a drachm of magnesia, given in combination with a tea- 
spoonful of lemon juice. The vascular excitement of the 
stomach is best subdued by dilute hydrocyanic acid, in the 
following formula (A. T. Thomson) : — 

]J Potassae Carbonatis, 3 ss. ; Succi Limonis Recentis, 
f 3 iv. ; Acid Hydrocyanici Diluti, miv. ; Vini Sem. Colchici, 
mxv.; Aquae Distillatae, f 3 vi. ; misce. Fiat haustus 4ta. 
quaque horae sumendus. 

The tone of the stomach is to be restored by small doses 
of bicarbonate of potassa, with from twelve to fifteen minims 
of the tincture of henbane, in a fluid ounce and a half of the 
infusion of cinchona. The eruption and itching disappear 
as the mucous membrane of the stomach and bowels return 
to a healthy state. The diet should be absolutely free from 
stimulants ; and tepid baths, at a temperature of 96 Fahr., 
used every morning for half an hour, are most serviceable. 
The bowels should be regularly relieved by such mild ingre- 
dients as are contained in the following formula for pills : 

fy Pilulse Hydrargyri, gr. vi. ; Pulveris Ipecacuanhae, gr. 
vi.; Extracti Colocynthidis Comp., gr. xii.; Ext. Hyoscyami, 
gr. xviii.; misce. Fiat pilulae duodecem. Sum. ij. h. s. quo- 
tidie (A. T. Thomson). 

Glycerine and emollient lotions are useful local applica- 
tions. I have found the itchiness greatly relieved by the 
following lotion of bitter almonds, rubbed nights and morn- 
ing over the parts affected : 

3 Amygdal. Amar. Numero, xx. vel. xxx.; Aquae Rosas, 

§ vii. Contunde et tere simul, dein cola, et adde Hyd. cor- 

rosiv. Sublim., gr. xii.; Ammoniae Hydrochloratis, gr. xii.; 



312 PUERPERAL CONVULSI ONS— PUERPERAL FEVER. 

Spt. Vini Rect., f i.; or, Dilute hydrocyanic acid may be 
used to the extent of two drachms to the eight ounces, omit- 
ting the corrosive sublimate ; or let borax replace the hydro- 
cyanic acid, and omit the spirits of wine. 

When the lotion has dried off, oxide of zinc ointment or 
glycerine starch ought to be applied to the parts all night. 

Puerperal Convulsions— See Convulsions, Puerperal. 

Puerperal Fever. — Definition. — " A continued fever, 
communicable by contagion, occurring in connection with 
childbirth, and often associated with extensive local lesions, 
especially of the uterine system. 

Treatment. — Having regard to the varied sources whence 
puerperal fever may take its origin, prophylactic treatment 
ought to be the first consideration; and especially the burn- 
ing question as to what ought to be the conduct of the med- 
ical practitioner in the face of perils of this kind (Priestley). 
Preventive measures are of vital importance, for such 
measures have been proven sufficient to arrest the develop- 
ment of the disease. 

Dr. W. O. Priestley concludes his admirable address as 
follows: — 

"The method, therefore, to be pursued for guarding lying- 
in women from noxious influences, consists of all those 
measures which prevent the formation of poisonous materials 
in her own system, and which secure her isolation from all 
contagion from without. In following out the first indica- 
tion, it is necessarv to provide, as much as may be practic- 
able, for a woman encountering her confinement in the best 
possible condition of health, by impressing upon her the 
necessity of obedience to natural laws during her pregnancy. 
If complications occur during pregnancy, they must be com- 
bated as the circumstances will permit. Dr. Barnes has in- 
formed us that albuminuria at the end of pregnancy is ex- 
tremely apt to go into puerperal fever. On these cases, 
therefore, a sedulous watch must be kept, the bowels must 
be carefully attended to, and other suitable treatment 
adopted. The process of parturition should be conducted 
with the view to the genital canal of the woman being ex- 
posed as little as may be possible to the effects of irritation, 
continued pressure, and laceration. After the birth of the 
child, a full and perfect contraction of the uterus should be 
secured, by seeing that the organ is not emptied too sud- 
denly, and that the hand follows the fundus down from 
above as its contents are expelled. Subsequently to de- 



PUERPERAL FEVER. 313 

livery, the various known methods should be practised 
which promote the contraction of the walls of the womb and 
the diminution of the uterine cavity; and any clots forming, 
should be removed from time to time during the hour after 
removal of the placenta. It is superfluous to say that the 
placenta should be extracted in its entirety when possible; 
and great care should be taken not to leave any detached 
portions adherent to the uterine walls. The same precau- 
tions should be observed, when practicable, in cases of 
abortion. If any considerable laceration of the perinaeum 
have taken place, the edges of the wound should immediately 
be united by sutures, not only for the purpose of restoring 
the perinaeum, but also to prevent contamination of the 
wound by putrid discharges. In the case of other wounds 
in the vagina or cervix uteri, especial care should be taken 
to keep them clean by repeated injection, and to leave as 
small a raw surface exposed as may be practicable. In all 
cases where the lochia are in the least degree offensive, the 
vagina should be well injected with Condy's fluid and water, 
or other innocuous disinfectant, twice in twenty-four 
hours, or oftener if necessary; and the injection may be 
carried into the uterine cavity, if it be much distended, and 
there is a suspicion that it harbors foetid contents. The in- 
jection of the wound-cavity, however, should be conducted 
slowly, carefully, and without force. These uterine injec- 
tions were practised long ago by William Harvey, and there 
is concurrent testimony in this and other countries of their 
marked utility in abating the symptoms, even when puer- 
peral fever has apparently set in. Next in importance is to 
take care that there is no faecal accumulation in the bowels, 
and to recollect that the existence of previous diarrhoea may 
be the indication that retained masses are lying in the in- 
testines and producing irritation there. It must be within 
the experience of many how acute febrile symptoms, ac- 
companied, it may be, by delirium or incipient mania, have 
passed away with a proper evacuation of the bowels. I may 
put it, in short, that, to promote recovery a r ter parturition, 
every direct or reflex source of irritation should be removed, 
pure air and water ensured, absolute cleanliness observed; 
and perfect quietude, mental and physical, should be en- 
joined. Nursing the child should also be recommended 
when the mother's condition permits, as puerperal ailments 
have been observed more frequent in women who have not 
suckled their children. To secure the isolation of a lying-in 



314 PUERPERAL FEVER. 

woman from noxious influences which may be communicated 
to her from without may be difficult, and in some cases per- 
haps impossible; but as Mr. Callender has informed us how 
surgeons have learned to banish, for all practical purposes, 
those affections which may be termed septicemic from surgi- 
cal wards of hospitals, so I cannot help thinking that the 
accoucheur will in time succeed in preventing the like affec- 
tions in puerperal women, so far, at least, as the hetero- 
genetic cases are concerned. We are all agreed as to the 
absolute necessity of preventing, directly or indirectly, any 
communication between cases of erysipelas and puerperal 
patients. We are agreed also as to the necessity of the mid- 
wifery practitioner avoiding all post-mortem examinations. 
His hands should avoid all contact with specific poisons or 
septic materials; and if perchance his fingers have touched 
anything suspicious, he should at once carefully and 
thoroughly disinfect them. The necropsies which seem 
most baneful are of those bodies which have recently died of 
erysipelas, peritonitis, zymotic disease, or any other inflam- 
matory and febrile affections; and in such instances the ac- 
coucheur should not even be present in the room when the 
dissection is made, as, though he decline to touch, yet his 
person and clothes may become infected by the poison. 
There may possibly be a doubt whether one who dissects 
bodies altered by decomposition or antiseptic injections, as 
they are commonly found in the dissecting-room of medical 
schools, is so liable to contaminate a puerperal patient as 
he who makes a necropsy soon after a death. Semmelweiss, 
however, believed that animal matter in a state of putrefac- 
tion would cause puerperal fever, and immediately lessened 
the mortality, during the fearful epidemic of puerperal fever 
which raged in the Vienna hospital in 1846 and 1847, by 
obliging all dissecting students to wash their hands in 
chlorine or chloride of lime before making vaginal examina- 
tions. Impressed by Semmelweiss's views and opinions, I 
endeavored, during my occupancy of the Chair of Obstetric 
Medicine at King's College, to prevent students frequenting 
the dissecting-room and post-mortem theatre from attending 
midwifery cases, and the result was a very small mortality in 
the outdoor maternity charity. This care about absolute 
cleanliness of the hands in attending labors should extend 
even to occasions when a medical man has had digitally to 
examine patients suffering from offensive discharges either 
proceeding from the surface or from the interior of the 



PUERPERAL FEVER. 315 

body- We have heard in this discussion that the discharges 
from cancer may produce fever in a lying-in woman; and 
this is probably true of other putrescent discharges. I have 
had grave anxiety, extending over some weeks, about a 
patient after her delivery; because I had gone straight from 
an instrumental case where labor had been so protracted 
that febrile symptoms had set in, and the passages had be- 
come inflamed, so as to pour out an irritating muco-purulent 
discharge. When a medical man has a bad case of puer- 
peral fever in his own practice, or is required to see one in 
consultation, he should certainly not go direct to another 
midwifery patient without first changing his clothes, besides 
careful ablution of his hands; and he will be all the safer in 
his ministrations if he adopt some of those precautions men- 
tioned by Dr. Swayne and others, such as using a Turkish 
bath, or the more radical measures for disinfection recom- 
mended by Dr. Wynn Williams. [No method, however, has 
been pointed out, or even alluded to, in the course of the 
discussion by which the septic poison could be got rid of 
should it have attached itself in any way to the body or 
dress of the accoucheur or nurse. We have more than one 
substance — one in particular — -that will not tolerate the 
presence of putrid animal matter or septic poison: this drug 
is iodine, which, as soon as it is brought in contact with 
septic matter, is converted into two harmless substances — 
acid and carbon. Let any one who has been in attendance 
on any case, whether a parturient female or any other, where 
there is any putrid emanation, wash his hands in water into 
which he has poured tincture of iodine, and I will answer 
for it he has no septic matter under his finger-nails. Again, 
if he fancy that his clothes, hair, and skin are saturated with 
it, let him go into the water-closet (I mention that as the 
smallest room in the house), place a few scales of iodine on 
a plate and put a spirit-lamp under it, and he will soon find 
himself surrounded by a violet vapor, which will fall upon 
him in a shower of minute scales, from which he has only to 
protect his eyes. If he then carry with him any of the 
puerperal poison, my whole theory of the disease must be 
wrong. One thing I can assert, that in my own practice I 
have never had a case of fatal puerperal septicaemia since I 
have used iodine as an antiseptic, now more than twenty 
years ago. Iodine is equally efficacious in warding off 
septicaemia in other surgical diseases. I have injected solu- 
tions of septic poison under the skin of guinea-pigs, and pro- 



3r6 PUERPERAL FEVER. 

duced death by septicaemia.. I have also injected some of 
the same solutions, into which I had dropped a few drops of 
the tincture of iodine, without producing any ill effects. It 
is needless to observe that the prevention and the cure of 
this disease go hand in hand together. . Should any septic 
poison be present in the puerperal woman, wash her out 
again and again with solution of iodine until the solution 
comes back the same color as it was thrown up. The tem- 
perature of the patient will probably be 103° or 104 , and 
it will go down in a very short time to 98 . This I have 
witnessed since the present discussion began. (Dr. Wynn 
Williams.)] 

" Many chemical substances have been recommended to 
be added to water for purifying the hands; iodine, chlorine 
and its compounds, sulphurous acid, cyanide of potassium, 
carbolic acid, and the permanganates. It matters not which 
agent is employed, so long as it is used carefully and effici- 
ently; and if it be necessary to disinfect clothing, this is 
readily done by exposing it in an oven to a high temperature, 
for which many upholsterers have a suitable arrangement. 
With all deference to Dr. Matthews Duncan, I have no doubt 
that every medical practitioner who earnestly desires to pro- 
mote the welfare of his patients and to keep himself blameless, 
should at once abstain from attending fresh cases of labor 
when one or more of those recently delivered by him have 
died with acute febrile symptoms, or are still so ill as to re- 
quire his constant visits. When, indeed, there is the remo- 
test suspicion that he may convey the poison in his own per- 
son, he should not incur the risk of disseminating it. How 
long he ought to absent himself from midwifery practice, is 
yet a moot point. Dr. Swayne thinks a medical man should 
seclude himself for a week only; others think a month 
hardly sufficient. The remarkable experience of Dr. Huntly, 
of Yarrovv-on-Tyne {Brit. Med. Jour?:., Feb. 27, 1875, 
p. 271), led him to believe that he actually generated poison 
in his own body, as the result of some faulty process, which 
he communicated to his patients. Taking all the circum- 
stances into consideration, I am disposed to recommend a 
week's seclusion after regular attendance has ceased on a sin- 
gle puerperal fever case. When a series of cases have occurred 
in the practice of any one medical man, he should absent 
himself from midwifery practice for a month at least. Dur- 
ing either the short or long interval of seclusion, the 
means for disinfection should be fully carried out. 



PUERPERAL FEVER. 317 

" Finally, I have to say a word or two as to the propriety of 
attending patients suffering from scarlet fever or other zymo- 
tic disease, and lying-in-women at the same time. After 
what has been said in this debate, I cannot expect the same 
accord of opinion as on other parts of the ground I have 
gone over; but I would earnestly beg those who have as yet 
had so favorable an experience, when attending the two sets 
of patients conjointly, to ponder well what has been said by 
others on the reverse side of the question. It cannot be 
expected that men in general practice,, who maybe in charge 
of a scarlet fever or small-pox patient, shall at once relin- 
quish all midwifery practice for the time being, because 
zymotic diseases are so prevalent that this would practically 
preclude their attending confinements altogether, or make 
their attendance on midwifery patients so irregular as to be 
unreliable. Nevertheless, in view of the dangers which have 
been indicated by various authorities, albeit their experience 
may seem to point to different conclusions, they are bound 
to exercise vigilance, lest perchance they slip into a pitfall 
unsuspected by them. In seeing an ordinary case of illness, 
a medical man rarely stays sufficiently long in the sick room 
to concentrate any considerable dose of contagium about 
him, and the after-exposure to fresh air in passing from 
house to house no doubt usefully dissipates any smaller 
quantity. I would suggest, however, to those treating in- 
fectious cases, and liable at the same time to be summoned 
to cases of midwifery, or who may be in attendance on 
puerperal women, that they should not stay long in the sick 
chamber; not undertake the duties of nurses, as Dr. Duncan 
puts it; that they should see puerperal patients before see- 
ing infectious cases, and never go from the infectious cases 
direct to the lying-in room, without changing clothes and 
the most careful ablutions. Some doctors change their 
clothes and wash with a disinfectant whenever they have 
seen infectious cases. Whatever either will, or may, con- 
duce to the wellbeing of patients, will, I am sure, not be 
regarded as either too irksome or troublesome by any mem- 
ber of our profession " {Brit Med. Journ., Jan. 8, 1876). 

If scarlet fever can be prevented, the number of puerperal 
fever cases would be diminished one-half (Hicks); and 
every possible step ought to be taken to remove the preg- 
nant female alike from the influence of scarlet fever and 
from erysipelas. Dr. Hicks observes, also, " with regard to 
the medical attendant, although I have found some fully 



3l3 PUERPERAL FEVER. 

aware of the risk of carrying scarlet fever and erysipelas to 
the woman in labor, yet I have met with not a few who 
either have not taken care, or have not been fully alive to 
the danger in which they are placing their patients." He 
considers it well to have three suits of clothes in use when 
attending such cases, keeping those out of use before a very 
warm fire, or hung out in the open air; the hands to be 
frequently washed and the nails short; and a good walk in 
the air should be taken before going to any other patient. 
Where there are partners, it is advisable for one to attend 
contagious cases, and leaving the other to manage the mid- 
wifery. With regard to the nurse, the tendency of women's 
dress to retain the fomites of contagion must suggest their 
frequent purification by disinfectants, and the use of material 
capable of being boiled in the process of washing, and of 
otherwise being subjected to the action of disinfectants. 
With regard to the prevalance of the disease in hospitals, 
the wards ought to be closed entirely against the admission 
of patients, at regular intervals, during which the process of 
purification should go on. The ward to be purified should 
then be filled with chlorine gas, in a very condensed form, 
for forty-eight hours at least; the windows, doors and fire- 
places being kept shut. The floors and woodwork should 
be covered with chloride of lime, mixed with water, to the 
consistence of cream. The woodwork should then be 
painted, and the walls and ceilings washed with fresh lime; 
the blankets and sheets should also be washed and heated 
in a stove to a temperature of 120 to 130 Fahr. The 
hospital beds should be stuffed with straw; and as soon as 
the case is concluded, the straw ought to be burned, and the 
covering of the bed washed and heated like the blankets 
and sheets (Collins's "Midwifery," 388). Patients threat- 
ened with puerperal fever ought to be isolated. 

With regard to medical treatment, pure air, nutriment, and 
stimulants are the agents best able to obviate the great 
depression which marks the commencement of puerperal 
fever. Quinine in large doses has been found useful after 
the bowels have been fully evacuated. It ought to be given 
till the physiological action of the drug is manifest, from the 
deafness and vertigo it produces. A form of quinine is now 
made soluble in warm water, which may be injected hypo- 
dermically. Opium is of great value. It has been given, to 
a large amount in the twenty-four hours, by Drs. Graves, 
Stokes, and others, since its great value became known. It 



PURPURA. 319 

must be given till incipient narcotism is produced; and the best 
evidence of its good effects is seen when the respirations become 
sensibly diminished from the great frequency they attain in 
puerperal fever. If they can be reduced to fourteen or to 
twelve, with a pulse below 100, a subsidence of tenderness, and 
of tympanitis, the amount of opium may be gradually lessened 
and finally discontinued (Clark). Warburg's tincture (suggested 
by Professor W. C. Maclean), has been found successful by 
Dr. Playfair in the treatment of puerperal fever. 

Purpura. — Definition. — A disease characterized by purple 
spots, patches, or merely points of effused blood, which are 
not effaced by pressure. They are usually met with on the 
skin alone ; but they may appear simultaneously on the 
mucous membrane, when they are sometimes accompanied 
with more or less hemorrhage. 

Treatment. — To treat this disease with success, it is neces- 
sary to ascertain the circumstances under which it becomes 
developed in each particular case. Its treatment may be 
comprised in the following measures : — The bowels ought in- 
variably, and without exception, to be first thoroughly and 
effectually evacuated by means of senna, aloetics, or calomel 
and jalap. Oil of turpentine administered in moderate and 
repeated doses, has also been recommended. Dr. Hardy, of 
Dublin, recommends the tincture of larch bark. He has 
long used it as a styptic and carminative tonic ; and it is 
" one of the most elegant forms of prescribing a terebinthi- 
nate " (Moore). Fifteen drop doses of the tincture may be 
administered every hour or eight or ten drops three times a 
day, afterwards increasing the dose according to the age of 
the patient and the necessities of the case. In young sub- 
jects otherwise robust, when the disease has appeared after 
violent exercise or excess, blood may be drawn from the arm, 
as practised by Dr. Parry of Bath. Under such circumstan- 
ces also the young patient should abstain from animal food 
in every form, and should subsist on boiled rice with whey, 
or the light subacid fruits, as grapes, oranges, strawberries, 
gooseberries, baked apples, and the like. His drink may con- 
sist of tamarind-water, or water acidulated with sulphuric 
acid. Under this plan most cases of the disease in the young 
will be speedily and readily brought to a favorable termina- 
tion. If symptoms of local uneasiness continue after the 
urgent phenomena have disappeared, leeches should be ap- 
plied in the neighborhood of the part ; and it will be proper 
to continue the periodical and regular evacuation of the ali- 



320 PYAEMIA. PYROSIS. 

mentary canal. When the spots have disappeared and the 
haemorrhage has ceased, the constitution recruits rapidly 
under the gradual but cautious use of light soups and fresh 
fruits and vegetables (Craigie). 

Pyaemia. — Definition. — A febrile affection associated with 
a morbid state of the system generally, the invasion being 
marked by frequently repeated severe rigors alternating with 
profuse sweatings, and usually sequent on some inflammatory 
and infective condition of wounds, suppurative inflammation 
of bone, the puerperal state, or surgical operations, which 
results in the formation of secondary lesions in the internal 
visceral organs (most frequently in the lungs, the liver, kid- 
neys, spleen, and brain), and also in the joints and connec- 
tive tissue. Sometimes, but not necessarily, it is associated 
with phlebitis or embolism. The blood becomes poisoned, 
and contains an excess of white corpuscles and of fibrine. 

Treatment. — The aim should be to prevent pyaemia by 
dressing wounds and injuries by Lister's antiseptic methods. 
Whenever the antiseptic treatment of Lister is properly car- 
ried out there is complete absence of pyaemia. The indica- 
tions are — (i.) To remove all those conditions which favor 
the degeneration, metamorphosis, or putrefaction of blood- 
clots or tissue in connection with wounds ; (2.) To subdue 
the force of the circulating current, so as to prevent excite- 
ment during the long and slow metamorphosis of a clot when 
it has formed ; (3.) To sustain the strength and allay the 
nervous irritability. Wine, brandy, rum, milk, strong animal 
soups, and nourishing diet, should be freely given from time 
to time, in small quantities. Opium should be given freely. 
Exposure of the patients to currents of fresh air — treatment 
in the open air, in fact — has been shown by Sir James Paget 
to be the most promising of success. 

The use of disinfectants, and attention to ventilation, give 
support to the belief that the poison is one generated among 
cases of accumulated severe wounds and open sores. The 
patient ought to be isolated. Condy's fluid, carbolic acid 
wash, and chloralum, are each useful disinfectants. Prepa- 
rations of iron are the most suitable tonics. 

Pyrosis. — Definition. — Paroxysms of pain at the cardiac 
or oesophageal region of the stomach, occurring in parox- 
ysms which do not cease till the patient vomits up a limpid 
colorless fluid, like water, cold and insipid to the patient's 
taste, but which sometimes gives an acid and sometimes an 
alkaline reaction. 



PYROSIS. 321 

Treatment consists in saline remedies, such as a drachm of 
the sulphate of magnesia, with fifteen minims of the tinct. 
hyoscyami, three times a day. Many other medicines have 
been recommended, as the tinct. kino, and compound kino 
powder, and mixtures of bismuth, especially Seller's. The 
compound tincture of benzoin, to the extent of one fluid 
drachm with mucilage, is most efficacious. (Baillie, Symonds). 
Sulphurous acid, 'in -doses mxxx, to one fluid drachm, thrice 
daily, and shortly before meals, is advocated by Dr. Lawson 
{Practitioner, Sept. 1868). It is especially useful where sar- 
cine ventriculi are present in the fluid evacuated. The diet 
should consist of animal food, and be otherwise nourishing. 
Oatmeal and brown bread must be avoided. 

Quinsy. — Defi?iition. — Acute inflammation of the tonsils, 
which may or may not lead to suppuration. 

Treatment must depend entirely on the stage at which the 
disease comes under notice. In the early period resolution 
may almost invariably be brought about by the administration 
of guaiacum, in the form of lozenges. Dr. Mackenzie pre- 
scribes a lozenge containing three grains of the extract of 
guaiacum mixed with black currant paste, every two or three 
hours. But I have found the drug most beneficially pre- 
scribed in the following formula: 

r^. Magnes. Sulph., 3vi.; solve in aquae 5 viil. ; adde 
Pulv. Guaiaci 3iss.; Pulv. Tragacanth. Co., 3ii. ; misce 
bene. One-sixth part of this mixture may be given every 
four hours till the bowels are freely moved. 

Minim doses of aconite tincture every hour will maintain 
a regular and steady action in subduing the inflammation. 
In addition, ice sucked constantly, and iced drinks, are most 
grateful to the patient; while, if ice cannot be obtained, cold 
thick gruel frequently affords relief. In other cases, how- 
ever, greater relief is experienced by holding hot water in 
the mouth, and by the inhalation of hot steam, combined 
with sedatives — such as benzoin or conium. A mixture of 
mucilage or gruel, containing nitrate of potash or borate of 
soda, and a small quantity of syrup of poppy, Batley's solu- 
tion of opium, or prussic acid, should be frequently but 
slowly swallowed in small quantities, in tea or tablespoonfuls; 
the amount of narcotic ingredient being carefully regulated, 
so that a definite quantity is consumed in a given time. Ex- 
ternally, a mustard poultice should be first applied, and af- 
terwards linseed poultices. The latter may be constantly re- 
peated until the attack subsides; spongiopiline may answer 



322 RACHITIS RELAPSING FEVER, 

better than the linseed poultices, and is more cleanly. If 
suppuration has commenced before the practitioner sees the 
case, great relief will be afforded by puncturing the abscess 
with a guarded knife; the incision should always be made 
towards the median line. After the abscess has been re- 
lieved, the recovery of the patient is usually very rapid; but 
the prostration is sometimes considerable, so that nourish- 
ment and stimulants are required in abundance. It has 
been already remarked that a patient who has once suffered 
from quinsy is likely to suffer again; and the question natur- 
ally arises as to what preventive treatment should be adopted? 
In those cases in which there is any chronic enlargement ot 
the tonsils, excision should be performed; but in some cases 
the glands, though extensively diseased, do not remain en- 
larged when the acute inflammation has passed away. Un- 
der these circumstances the tonsil may be amputated during 
the attack of quinsy. This plan of treatment is commonly 
adopted in Germany on its own merits, without any question 
as to the recurrence ot the inflammation. 

Rachitis — See .Rickets. 

Relapsing Fever. — Definition. — A continued fever, hav- 
ing a very abrupt invasion and short duration, characterized 
by an abrupt relapse occurring after an interval of apparent 
health of about a week. There is no eruption on the skin, 
nor any specific lesion associated with this fever, which is 
marked by rigors, chilliness, severe headache, vomiting, and 
often jaundice; a white moist tongue, epigastric tenderness, 
confined bowels, enlarged liver and spleen, high-colored 
urine, a frequent, full, and often bounding pulse, pains in the 
back and limbs, restlessness, and occasionally delirium. 
These symptoms abruptly terminate by an exceedingly copious 
perspiration between the fifth and the eighth day; and after 
a complete apyretic interval (during which the patient may 
be so well as to get up and walk about), an abrupt relapse su- 
pervenes on the fourteenth day, counting from the first com- 
mencement of the fever. The relapse runs a similar course 
to that of the primary paroxysm, and terminates between the 
third and the eighth day. In some cases a second, third, 
fourth, and even fifth relapse may occur. Death is apt to 
happen from sudden syncope, especially after the excessive 
perspiration; or from suppression of urine and coma. 

Treatment. — All physicians agree that in. the primary at- 
tack little medicine is required after opening the bowels by 



RELAPSING FEVER. J2J 

castor-oil; or by five grains of the compound colocynth 
mass; or by two grains of blue-pill, and three grains of ex- 
tract of hyoscyamus given at night, and followed -in the 
morning by two drachms of the sulphate of magnesia in 
compound infusion of roses (Murchison). The symptoms 
are not readily under the control of remedies; the vomiting 
is often especially persistent. Five grains of calomel, with 
one grain of opium, has been found more efficient in subdu- 
ing the severity of this symptom than counter-irritation or 
effervescing draughts. The violence of the headache in 
well-fed, or otherwise healthy patients, is best subdued by 
leeches or cupping; and in the poor, weakly and ill-fed, by 
blisters to the nape of the neck, or by dry cupping there. 
Till the crisis comes, the symptoms may be mitigated, but 
not altogether relieved, and cases of ordinary severity are 
better left to nature without interference on the part of the 
physician. Active purging is to be avoided; and the action 
of the kidneys is to be kept up by the frequent use of small 
doses of nitre (Ross, Henderson, Cormack, Wardell, Mur- 
chison). " By keeping up the action of the kidneys from 
the first" we may " prevent the occurrence of uraemic intoxi- 
cation, which is one of the main causes of death in uncom- 
plicated cases." With this end in view nitre is to be given 
as follows: — From one to two drachms of nitre are to be dis- 
solved in two pints of barley-water, acidulated with a drachm 
of dilute nitric acid, and sweetened with a little syrup. 
This quantity is to be used up during the twenty-four hours. 
Acetate of potash and nitric ether may be used for the same 
purpose; but the nitre has the additional advantage of keep- 
ing open the bowels (Murchison). Contamination of the 
blood with urinary products is the great danger in cases of 
relapsing fever; and therefore particular attention must be 
paid to the state of the urine, especially towards the period 
ol the first crisis. When the daily amount is much reduced, 
or if entire suppression should ensue, and particularly if 
stupor, confusion of thought,or drowsiness should supervene, 
the bowels are to be freely moved by compound jalap powder, 
or by a turpentine enema. Determination to the skin 
should be promoted by the hot-air bath; and saline diuretics 
may be given every two or three hours. No means hitherto 
discovered will prevent the occurrence of the relapse. The 
surface of the body should be frequently sponged over with 
cold or tepid water. Stimulants are not usually necessary, 
but they may be required in the stage of languor or exhaus- 



324 REMITTENT FEVER. 

tion ensuing on the crisis, or in cases where great debility- 
has preceded the attack. If any anaemia exists, or if an 
ansemic murmur can be detected, stimulants must be given 
early. When jaundice appears, nitro-hydrochloric acid 
should be given in combination with nitre, as in the follow- 
ing formula: — Twenty minims of hydrochloric acid, with 
ten minims of nitric acid, every three hours, each dose 
diluted with the drink of nitre and barley-water already pre- 
scribed (Murchison). 

Remittent Fever. — Definition. — Febrile phenomena 
of malarious origin, characterized by irregular re- 
peated exacerbations and remissions being less 
distinct in proportion to the intensity of the fever, so 
that in malarious yellow fever the exacerbations and 
remissions are so connected that the fever resembles a 
continued fever. There is great intensity of headache, 
the pain darting with a sense of tension across the forehead. 
It is accompanied by functional disturbance of the liver, and 
frequently by yellowness of the skin, as in malarious yellow 
fever, in which, however, the urine is not suppressed, and 
continues free from blood and albumen. The malignant 
local fevers of warm climates are usually of this class. 

Treatment. — With fever so various in its degrees of severi- 
ty, it is not possible to do more than indicate the nature of 
the treatment which may be followed, as every special case 
must be prescribed for and treated by its own special indi- 
cations, and with a due regard to the nature of the prevail- 
ing epidemic. The best possible hygienic arrangements 
should be made, especially to secure efficient ventilation, 
with a plentiful supply of fresh air. In every form and va- 
variety of the fever one of the most important guides in the 
treatment is to be derived from the nature of the prevailing 
disease, whether endemic or epidemic, whether sthenic or as- 
thenic, and to study each individual case in relation to the 
prevailing type. First, the duration of the stage of the fever 
must be ascertained — i. e., whether it be of some hours' or of 
some days' duration, and whether, when the practitioner sees 
the patient for the first time, the actually existing paroxysm 
is at its accession or its decline. 

Regarding the method of treatment of remittent fever, my 
friend and colleague, Prof. W. A. Maclean, whose extensive 
experience in India gives authority to his conclusions, writes 
in the following terms :— 

" I have been led to take a view of the treatment of mala- 



REMITTENT FEYER. 325 

rial fevers generally, and remittent fever in particular, differ- 
ing from that laid down by many authors. It appears to 
me that the so-called antiphlogistic treatment, so much in- 
sisted on by many writers, is based on the belief that the 
phenomena observed in a case of remittent fever are conse- 
quent on a process of inflammation. It is only on such a 
belief that antiphlogistic treatment can be justified. During 
the exacerbation of a remittent fever there is violent disturb- 
ance both of the vascular and nervous systems. Almost 
every organ, almost every function suffers, — the gastric in- 
intestinal membrane is affected, the liver and spleen suffer, 
the brain is involved, for rending headache and delirium 
are often present. Is it rational to suppose that an inflam- 
matory process can be going on at one and the same time in 
all these various organs ? Do the appearances observed 
post-mortem give any support to such a doctrine ? If not, 
on what principle can spoliative treatment be justified ? Is 
it not rather the case that this terrible disturbance of so 
many organs is due to the presence in the blood of a subtle 
poison acting on them all ? If so, surely the guiding princi- 
ple of the physician in his treatment should be to counter- 
act this poison, to neutralize it, or to expel it from the sys- 
tem, and so to prevent a recurrence of the exacerbation. 
This is the principle on which I have long acted, and I am 
satisfied that it is at once a safe and successful one. In qui- 
nine we have such an antidote — a therapeutic agent of unri- 
valled efficacy, which, if skillfully used, will rarely disap- 
point the expectations of the practitioner. 

" It is always, of course, advisable to have the bowels 
thoroughly evacuated ; and if the patient is seen when his 
stomach is loaded, it is well to evacuate its contents by an 
emetic. In ardent remittents, however, there is generally 
little call for this, as obstinate vomiting is almost always a 
troublesome symptom, sometimes requiring to be checked. 
This done, the period of remission must be watched for, and 
the moment it arrives, quinine in a full dose should be given 
— not less than fifteen grains in the case of an adult. If the 
irritability of stomach be so urgent that the remedy is reject- 
ed, while measures must be adopted to allay it — such, for 
example, as alkaline remedies in combination with dilute 
hydrocyanic acid, turpentine stupes, or even a blister to the 
epigastrium — time — precious time — should not be lost. Qui- 
nine should be given by the rectum, in a full and efficient 
dose. By mouth or by rectum, or by both, quinine in 



326 REMITTENT FEVER. 

quantity sufficient to induce some of the symptoms of cin- 
chonism, should be given before the time of expected exac- 
erbation. According to my judgment and experience, it is 
bad practice to withhold quinine until an impression has 
been made on the force and frequency of the heart's action, 
from fear of increasing headache, causing congestion of or- 
gans, or the like. An impression on the force and frequency 
of the heart's action is best attained by arresting the parox- 
ysm ; and this is done most quickly, simply, and effectively 
by the early administration of quinine. I have over and 
over again had patients brought to me from the malarial 
quarters of the city of Hyderabad, in whom it was impossi- 
ble to distinguish any period of remission — the tongue black 
and dry, sordes on the teeth, the skin hot and parched, the 
pulse enormously quick, the intelligence feeble or gone — all 
pointing to a system so charged with malarial poison as to be 
well nigh overwhelmed. In such cases quinine, with concen- 
trated beef-tea and brandy, are urgently called for, and should 
be administered freely ; and it is astonishing how men, by 
such measures, are often snatched from impending death. I 
have seen in a few hours consciousness return, a striking re- 
duction in temperature, in the frequency of the pulse, with a 
remarkable accession of force and volume, follow the treat- 
ment indicated above. I do not advise, and never used qui- 
nine in the heroic doses advised by some. I have never ex- 
ceeded twenty grains ; but within such reasonable limits I 
have never seen it aggravate headache. On the contrary, I 
believe that in remittent fever — in fact, in all forms of malar- 
ial fever with which I am acquainted — I believe quinine to 
be a powerful remedy in quieting the tumultuous action of 
the circulation disturbed by the presence of this terrestrial 
poison. For some years past Warburgh's tincture has been 
much used in the treatment of malarial fevers in Southern 
India. It is a secret remedy, and therefore open to the ob- 
jections very properly urged against all such remedies. It 
is now known that quinine enters largely into this remedy, 
the composition of which is published in the Lancet, Vol. II., 
1875, p. 716. I have given this 'tincture' a fair trial in 
some of the gravest forms of malarial fever, and it has also 
been extensively used by some of the most experienced offi- 
cers of the Madras army ; and I do not hesitate to say that 
I think it a valuable remedy. I have known it arrest at once 
some of the severest cases of remittent fever, no exacerbation 
appearing after the second dose. It almost invariably acts 



Remittent fever. 32? 

as a powerful diaphoretic — the most powerful with which I 
am acquainted. I have seen patients, under the influence of 
this remedy, saturate not only the bed-clothes, but the very 
mattress, the patient's room and his person for days after 
giving out a strong odor of the medicine. For this reason it 
requires to be used with extreme caution, if at all, in the 
adynamic form of the disease. 

" In urgent cases I follow the practice of the American 
physicians. I do not wait for a remission, but give quinine 
at once ; and in all I am conservative of the patient's 
strength. I have seen violent delirium follow, free leeching 
of the temples, and over and over again seen extreme and 
dangerous prostration follow depletive treatment, and that in 
cases where the violence of the disturbance indicated power; 
but these signs of power in the system are often most delu- 
sive, and, if combated by depressing measures, we must be 
prepared for sudden signs of collapse. Against the system 
of treating this fever by saturating the system with mercury, 
I enter my strenuous protest. I know nothing more deplora- 
ble than the condition of a patient whose constitution, al- 
ready depressed by the presence of malaria, is further satu- 
rated by another poison which acts as a powerful ally of the 
first." 

In the asthenic form of remittent fever, such as that so 
well described by the late Dr. Murchison as prevailing in 
Burmah, it is necessary to exercise great caution in deple- 
tion. All the cases he relates which had been freely bled 
exhibited the most aggravated typhoid symptoms, and most 
of them died. Even in the instance of young and robust re- 
cruits, low adynamic typhoid symptoms were sure to super- 
vene in a short time after blood-letting ; and, even although 
it gave temporary relief, it was certain to aggravate, if not to 
induce, the subsequent typhoid condition. If the headache 
is very severe and the pulse full ; if the hair be cut short, or 
shaved off the scalp, cold lotions applied to the head, or the 
cold douche kept up for ten minutes at a time, gives great 
relief, and is the preferable remedy (Murchison). As soon 
as possible after the commencement of the paroxysm the 
bowels should be cleared out with a purgative of calomel 
and compound jalap powder ; or by colocynth, antimonial 
powder, and calomel. If typhoid symptoms betray them- 
selves, stimulants, such as wine and brandy, must be given ; 
but, as in intermittent fever, "quinine is undoubtedly the 
sheet-anchor," and it is best given, as in the former fever, in 



328 RHEUMATIC FEVER RHEUMATISM, ACUTE. 

one large dose of twenty grains in solution at the very com- 
mencement of a remission. Carbo-azotic or picric acid has 
been lately introduced as an active remedy in the treatment 
of malarious fever. Prepared by Calvert, of Manchester, it 
is of a light yellow color ; and in doses of two grains, cau- 
tiously repeated, it is to be pushed till the patient gets yel- 
low-skinned. 

The period of convalescence demands no less careful at- 
tention on the pftrt of the medical attendant, especially as to 
diet and a timely removal from all malarious influences, by a 
sea voyage, or a change of climate. It is to the mismanage- 
ment of convalescence, and a too early discharge from hos- 
pital principally, that we must refer the numerous and fatal 
relapses in the fevers and dysenteries of our seamen and sol- 
diers (Martin). 

Rheumatic Fever. — See Rheumatism, Acute. 

Rheuatism, Acute. — Definition. — A specific febrile dis- 
order, due to a morbid state of the system by constitutional 
development, and expressed by inflammation of a peculiar 
non-suppurative kind in the fibrous tissues about or surround- 
ing the joints, especially in the white fibrous tissues — such, 
for instance, as the sheaths of the muscles and muscular 
fibres, tendons, aponeurosis, bursas, capsular ligaments, per- 
iosteum, and pericardium. Many joints may be affected at 
the same time or in succession. The various local pheno- 
mena of the disease have a tendency to shift from part to 
part, the most remote from each other; and the febrile state 
is accompanied by profuse acid excretions from the skin, by 
the separation, in some cases, of large quantities of uric and 
sulphuric acid through the kidneys, and by a highly fibrinous 
condition of the blood. 

Treatment. — It seldom if ever happens that the cure of 
rheumatism can be entrusted to any single remedy. The 
constitutional nature of the disease, as already indicated, 
points to various methods and combinations of treatment as 
most likely to lead to a successful issue. A successful issue 
in a case of rheumatism means that the attack should be 
passed through without any permanent organic mischief be- 
ing left behind. The treatment of rheumatism must pro- 
vide, (1.) for the acute attack; (2), for the management of the 
system as regards those conditions of the life of the patient 
which may have been found to contribute to the constitu- 
tional development of the disease. 



RHEUMATISM, ACUTE. 329 

In the acute attack the patient must be made — (i.) 
comfortable, being protected from pain and exposure to 
cold air, especially as regards the joints; (2.) to encourage 
free excretion from the skin especially, and from the kid- 
neys. The general management of- the patient is therefore 
all important. No linen must touch the skin. A flannel 
shirt must be worn next its surface, and the patient must be 
put between soft blankets. u Bedding in blankets reduces 
by a good three-fourths the risk of inflammation of the 
heart run by patients in rheumatic fever, diminishes the in- 
tensity of the inflammation when it does occur, and dimin- 
ishes still further the danger of death by that or any other 
lesion; at the same time it does not protract the convales- 
cence " ("Chambers's Lectures, chiefly clinical," p. 147). 
The patient ought to be carefully wrapped up in blankets of 
the newest and fluffiest kind that can be got, which are to 
be so arranged as to shut off all accidental drafts of air (Dr. 
Roberts). On no account are the bed-clothes to be thrown 
off, however warm the surroundings may become; for an 
evenly high temperature to the skin, combined with absolute 
rest, are of the greatest value in rheumatic fever. These 
two conditions are worth all other means of relief put to- 
gether (Dr. King Chambers). The bed should be protected 
by screens from draughts of air. All the joints, whether 
affected or not (i.e., the limbs), ought to be enveloped in 
cotton wool, a layer of which ought also to be put over the 
chest on both sides, with an arrangement for permitting the 
region of the heart to be easily got at for its occasional ex- 
amination <Dr. Roberts). On the other hand, the following 
are the indications which have guided Dr. R. Southey of St. 
Bartholomew's Hospital, London, in the treatment of acute 
rheumatism: — 

"To relieve local pains; to reduce fever; to diminish the 
gravity of the various complications; and to promote early 
and complete convalescence. I do not consider that the 
materies morbi are eliminated either by sweating or by purg- 
ing. A spring bed with a tightly stuffed horse-hair mattress 
over it, is that which rests and supports the trunk and 
limbs, and relieves the joints most. I am no advocate for, 
and have never allowed my patients .to be placed between 
the blankets instead of the sheets; neither will I permit 
flannel bed-shirts to be worn. The object I have in view is 
to keep one uniform temperature about them, which the bed 
provides for; but not to keep the patient swathed in flannel 



330 RHEUMATISM, ACUTE. 

reeking and saturated with decomposing perspiration. As a 
matter of fact I observed that a large proportion of hospital 
rheumatic patients were persons who habitually wore thick 
flannel shirts and under shirts, and did not change them very 
often. Cotton shirts and cotton sheetings are better suited 
than linen to rheumatic people. My practice has been to 
keep my rheumatic cases cool rather than hot. They are 
certainly easier in consequence." 

As to medical treatment, venesection, calomel, combined 
with purgatives, colchium, and opium, are the remedies 
which have been hitherto most generally made use of in the 
treatment of acute rheumatism. To the success of each of 
these remedies the late Dr. Latham has borne his testimony, 
" so far as that, under the use of each," he writes, " I have 
seen patients get well." No disease has been treated by 
such various and opposite methods, so that " acute rheuma- 
tism has experienced strange tilings at the hands of medical 
men." " Had he written in these days Dr. Latham would 
have had many other strange things " to add to his list : — 
Alkalies, acids, salines, hot water, cold water, lemon juice, 
( itric acid, chloral, belladonna, iodide of potassium, ergot, 
digitalis, aconite, guaiacum, emetics, sulphur, antimony, per- 
chloride of iron, quinine, iodine, plaster of Paris bandages, 
galvanism, subcutaneous injection of carbolic acid, blisters, 
podophyllum, cynara, propylamine, cbloro-hydrate of trime- 
thylamine, and last, but not least, salicine, salicylic acid, and 
salicylate of soda. All these and many more remedies have 
been used in rheumatic fever; and each has been extolled 
as more potent than all the rest (Dr. E. Markham Skerritt, 
Brit. Med. Jown., July 28th, 1877, p. 104). But as the dis- 
ease, when uncomplicated, tends to terminate sooner or later 
in recovery, and may sometimes subside with marvellous 
rapidity under every variety of remedy, it is obvious that no 
sound inference can be drawn as to the success of any par- 
ticular method of treatment, unless such treatment has been 
largely adopted in cases of exactly similar severity — as esti- 
mated by the correlation of pulse, respiration, and tempera- 
ture (measured by thermometer) — and been attended with 
tolerably uniform results. Each and every plan of treatment 
which has therefore been hitherto proposed is regarded by 
the profession as unsatisfactory. (See account of a discus- 
sion upon a paper read by Mr. Dickinson to the Royal 
Medico-Chirurgical Society of London, and reported in the 
Medical papers of 21st June, 1862). If in one person's 



RHEUMATISM, ACUTE. 33I 

hands any particular remedial course has proved efficient, it 
has signally failed in those of another. If at one time a 
remedy has proved efficacious, it has been found inert or in- 
jurious at another, under different circumstances of age, sex, 
constitution, and the like. These facts ought not to appear 
strange to those who consider the true nature of the disorder, 
and the variety of circumstances under which the physician 
may be called upon to minister to his patient's relief. Bleed- 
ing, which in the young, plethoric, and robust, may be neces- 
sary to allay excessive vascular action and cause free secre- 
tion, may in the weakly induce irritability of the heart, and a 
consequent attack of cardiac inflammation. Opium, which 
in one person may prove of the greatest service in promoting 
free perspiration and in allaying the general irritability of the 
system, may in another check the biliary, "lock up" other 
secretions, and thus prevent the elimination of effete or 
deleterious matter from the system. The continued use of 
calomel, and constant purgation by it, may be beneficial to 
one patient, by removing large quantities of unhealthy secre- 
tions, but may unnecessarily exhaust the strength of another, 
and tend very greatly to impede recovery. So, in regard to 
every remedy which has been proposed: what is useful at 
one time may prove useless, or positively injurious, at an- 
other. Special attention has also been drawn to the fact by 
the mint-water treatment of Sir William Gull and Dr. Sut- 
ton, " that rapid recoveries were often made when the only 
treatment was good nursing ;" that symptoms subside wholly 
irrespective of treatment between eight and ten days. The 
average duration of acute symptoms under treatment was 9.1 
days; or from the beginning of the disease 17 days. With 
regard to heart complication it is affected early in the dis- 
ease — generally within the first week; and if it escaped for 
a week it would probably escape altogether. Sir William 
Gull and Dr. Sutton thus came to the conclusion that drugs 
had little influence in shortening the disease; and many 
drugs have had the credit of warding off heart complications 
simply because the time for the occurrence of these lesions 
had passed before the medicine was given. 

To learn how to adapt our present remedies to the exigen- 
cies of each particular case is what is now most of all 
required. Acute rheumatism is manifestly a highly inflam- 
matory disease, but of a peculiar constitutional origin, as has 
been fully shown. The blood drawn presents a more copious 
layer of "buff" than it does in most other diseases. The 



332 RHEUMATISM ACUTE. 

proportion of fibrine being greatly increased, we can hardly 
feel surprised that bleeding has been largely had recourse 
to. But although bleeding has been extensively adopted, 
the profession has hitherto been much divided as to the ad- 
vantage derived from the practice. A careful analysis of 
conflicting evidence leads to the conclusion that general 
blood-letting is not to be recommended, and on pathological 
grounds it is not justifiable. No advantage is gained as to 
time ; but temporary, if any abatement of sufferings follows 
its use; lastly, this mode of treatment appears to have caused 
in the practice of Bouillaud an unusually large number of 
cases of myocarditis — a larger number, indeed, than has been 
witnessed by any other person in the profession. A predis- 
position to cardiac inflammation is doubtless engendered by 
copious and repeated blood-letting : one-half the cases of 
acute rheumatism became so complicated after treatment by 
bleeding (Dickinson;. It undoubtedly increases the irrita- 
bility of the heart, and consequently favors the production 
of cardiac complication. General blood-letting is only bene- 
ficial in first attacks occurring in young, robust, and othei- 
wise healthy persons, particularly in those cases which are 
marked by unusual severity of their symptoms, or are unac- 
companied by free perspiration. It ought at all times to be 
cautiously employed and carried to a small extent only — viz., 
from eight to twelve ounces, according to the age and 
strength of the patient, the object being to favor the action 
of other remedies, and to promote free secretion by its use, 
rather than to arrest or cut short the disease (Latham, Fuller). 
If, therefore, perspiration is free, and remedies are absorbed, 
blood-letting is not to be thought of. In mild cases it is 
unnecessary; in the delicate, and those of weakly constitu- 
tion, it is inadmissible ; and in the well-expressed rheumatic 
diathesis, or when the disease is distinctly ascertained to be 
hereditary, it utterly fails in modifying the morbid action, 
is ill-borne by the system, and therefore should only be prac- 
ticed under the extremely urgent and specific conditions 
just mentioned (Willan, Fordyce, Alison, Todd, Watson, 
Fuller, Dickinson). If circumstances, therefore, ever war- 
rant its employment, it ought necessarily to take the lead of 
all other measures, and may be used in the young, plethoric, 
and robust, in whom secretion is insufficient, whose pulse is 
full and bounding, and whose skin is dry, hot, and burning. 
A single bleeding is sufficient to relieve the excessive con- 
gestion, on which the want of secretion in a great measure 



RHEUMATISM, ACUTE. 333 

depends, and which forms an obstacle to the action of those 
remedies on which we rely for effecting a cure. Active pur- 
gati«n is also to be avoided. It is injurious for three reasons: 
First, Because it is not necessary to the cure of the patient, 
and, like bleeding, tends greatly to reduce his strength and 
protrac*" recovery. Second, Because, from the nature of the 
complaint, the patient is quite incapable of moving, and his 
sufferings are aggravated, his irritability is increased, and his 
heart's action accelerated, by the repeated shifting of his 
position, which is rendered necessary by the calls of nature. 
And, Third, Because it necessarily gives rise to more or less 
exposure, which must be prejudicial to a person bathed in 
perspiration (Fuller). After having obtained one full dejec- 
tion by the following searching combination, which will secure 
an abundant flow from the glandular follicles of the intestinal 
mucous membrane, the subsequent aim should be to obtain 
merely a single free evacuation every morning. 

I£ Calomel, gr. v.; Pulv. Jalap. Co., 3ij.-3i. ; Pulv. 
Zingiberis, gr. iii.-gr. v. ; misce — to be taken in a little 
milk. ■ 

A daily evacuation of the bowels is then to be maintained 
by mild salines, such as the potassio-tartrate of soda, sulphate 
and carbonate of magnesia, taken as a draught in the morn- 
ing ; and preceded every second night by a Plummer's pill 
at bedtime, combined or not, according to circumstances, 
with a full dose of opium ; or, a grain of the watery extract 
of Barbadoes aloes may be found sufficient on alternate days. 
If the bowels act only once a day, a laxative dose of calomel 
and opium may now and again be prescribed, with the view 
of modifying the character of the intestinal secretions. Dark- 
colored and offensive stools indicate the necessity for the 
dose, followed by a draught of infusion of senna, together 
with half an ounce of the potassio-tartrate of soda, and twenty 
minims of the vinum colchici ; and these should be repeated 
every evening and morning till healthier evacuations are ob- 
tained — i. <f., till the motions are light-colored, more bilious, 
and less offensive. Opium may be given with the greatest 
advantage in the early and most painful stage of the disease 
occurring in adults, to the extent of six or eight grains of 
the powder in twenty-four hours, or two grains of the extract 
of opium may be given every night ; to children, half-grain 
doses of the powder, or less, according to age, may be given 
every three or four hours. The bowels require to be kept 
open during its use ; and its influence requires to be closely 



334 RHEUMATISM, ACUTE. 

watched. If the urine increases in quantity, if the motions 
become more healthy in appearance, and the coated tongue 
cleaner and less red, the influence of opium is beneficial. It 
encourages sweating. Hydrate of chloral is another valuable 
soporific and sedative. Colchicum administered alone is a 
dangerous agent ; but its virtue as a remedy may be obtained 
in small doses in combination with other medicines. It may 
be given with small doses of ipecacuanha, alkalies, and opium. 
It promotes evacuation by the kidneys. It is only in some 
cases, however, that it appears to be of service. It is far less 
efficacious in the weak and nervous than in the more robust 
and less easily depressed, and of less value in purely fibrous 
rheumatism than in cases where the synovial inflamma- 
tion predominates. It has proved less advantageous in pro- 
portion as the fever has exceeded the articular swelling, and 
as the urine has been less highly charged with lithates. The 
operation of this remedy must under all circumstances be most 
carefully watched \ and a daily evacuation from the bowels 
must be secured during its use If the lithates disappear 
from the urine, if the pulse becomes weak, if faintness, nausea, 
or purging supervene, the colchicum must be at once dis- 
continued; but till some one of these symptoms occurs, a 
grain or a grain and a half of the acetous extract or the 
inspissated juice, or from fifteen to twenty grains of the 
wine of colchicum, may be safely and with advantage admin- 
istered two or three times a day (Dr. Fuller). 

Veratria is to be used in small doses The ordinary for- 
mula recommended is: 

Veratria and extract of opium # one grain each, to be di- 
vided into ten pills, of which two pills are to be given the 
first day, three the second, four the third, five the fourth, 
and so on, increasing one pill each day, until the condition 
of the pulse or the irritation of the mucous membrane com- 
pels a diminution. 

The beneficial effects of guaiacum are obtained in those 
cases which are unaccompanied by perspiration, and in 
which the excretory organs are gently excited by the action 
of the remedy; but when the patient is perspiring freely, and 
when it neither purges nor causes diuresis, very little benefit 
is obtained from its use. Combined with bitartrate of po- 
tass, sulphur, and rhubarb, it constitutes the chief ingredient 
in a celebrated empirical formula, well known to army med- 
ical officers under the name of " Chelsea Pensioner," which 
has obtained a high reputation amongst old soldiers as a 



RHEUMATISM, ACUTE. 335 

remedy for the " pains/' or chronic rheumatism. In some 
large hospitals, both civil and military, this remedy is in 
common use in the treatment of old chronic cases. Its com- 
position is as follows: 

1^. Pulv. Guaiaci, | i.; Pulv. Rhei, 3ji.; Bitart. Potassae; 
Sulphur Sublim., a a 3 i. : ; Pulveris Nucis Moschatae, |ii.; 
Mel. vel Glycerina, lbi.; miscebene. Of this compound two 
large spoonfuls may be taken night and morning. 

Another formula is the following: 

IJ. Pulv. Sinapis; Sulph. Sublim., a a 3 iii. ; Pulv. 
Guaiac. 3iss.; Pulv. Rhei, Potas. Nitratis, a a gr. xlv.; 
misce bene. Honey, treacle, or glycerine, sufficient to make 
the dose into an electuary, is the most convenient form for 
use, of which a teaspoonful every alternate evening is use- 
ful; or a teaspoonful of the powder may be mixed with 
milk, and so taken at bedtime. 

But, the general treatment ot the constitutional disease 
originally recommended by Brocklesby (1764), and followed 
successfully by Macbride (1772), Basham, Fuller, Furnival, 
Garrod, and now by many other physicians, is that by alka- 
lies and the neutral salts, with colchicum, a little antimony 
being sometimes added, with the occasional aid of calomel, 
used only as a remedy to promote evacuation from the 
glands of the intestinal mucous membrane. Alkalies, and 
the neutral salts, may be given in combination with colchi- 
cum, full doses of opium, and a little antimony. They aid 
disintegration, and increase the elimination of sulphuric acid 
by augmenting the alkaline condition of the blood (Parkes). 
The alkalies ought to be given largely. Patients lose their 
pains under their influence, and proceed rapidly to conva- 
lescence. The pulse is generally tranquillized within forty- 
eight hours from the commencement of the alkaline treat- 
ment; and if in twenty-four hours the pain is lulled and the 
local inflammation greatly subdued, the constitution is evi- 
dently coming under the influence of the remedy. The du- 
ration of rheumatic fever is undoubtedly shortened by alka- 
lies: — 6 to 7 days, as compared with 9.1 days of mint-water 
cure, and the total duration 13 to 14 instead of 17 (Garrod . 
The form in which the remedy is to be given is 
that of a simple saline or nitrate draught, to 
which from two to three drachms of the potas- 
sio-tartrate of soda may be added, with ten to fifteen minims 
of the vinum colchici, from fifteen to twenty minims of the 
vinum antimonii, and from ten to fifteen minims of the tine- 



33& RHEUMATISM, ACUTE 

ture of opium, or of Battley's sedative solution, to prevent 
the salt running off by the bowels. This draught is to be 
repeated for the first twelve or twenty-four hours, at inter- 
vals of three or four hours, according to the strength of the 
patient and the severity of the attack; and if pain is exces- 
sive, a pill containing half a grain to a grain and a half of 
opium, or an equivalent dose of Dover's powder, may be 
given once or twice daily. In the use of these remedies, 
constipation and narcotism are to be avoided on the one 
hand, and diarrhoea to be guarded against on the other 
(Fuller). If the saline treatment is to be used alone, then 
a solution of nitrate, acetate, and bicarbonate of potash 
should be given in such doses that ten or twelve drachms of 
the two latter salts together are taken in the twenty-four 
hours. Half a drachm of the acetate, with a drachm or a 
drachm and a half of the bicarbonate, and ten grains of 
nitre, dissolved in an ounce and a half of water and sugar, 
or lemonade, or barley water, and given every two hours, 
night and day, until the joint affection and pains have be- 
gun to yield in severity, are sufficient for this purpose. Or 
the following: Nitrate of potash, one drachm; acetate of 
potash, three drachms; water or barley water, eight ounces; 
— of this mixture one ounce for a dose ought to be repeated 
every two, three, or four hours, according to the urgency of 
the symptoms; or from twenty to sixty grains of the bicar- 
bonate of soda, or of potash, may be given every three or 
four hours in half a bottle of soda or seltzer water; or in an 
effervescent citrate of ammonia, or potash draught (Tanner). 
This is the treatment which most of all seems efficient in 
warding off the cardiac complications; and Dr. J. J. Furni- 
val was the first (after Prout) to direct the attention of the 
profession to the use of alkaline remedies (carbonas potassse) 
in the treatment of Rheumatism, and especially as a pre- 
ventive of the cardiac complication (Lancet, 1841, p. 305). 
The good effects of such treatment as a preventive of the 
cardiac affections have been since fully demonstrated by 
Fuller, Garrod, Basham, Goodfellow, and others. Dr. Dick- 
inson has given statistics in which the percentage of heart 
disease occurring under the alkaline treatment was 2.1 as 
against 31.7 under various other remedies. To be effective, 
the remedy must be carried out with energy and persever- 
ance, till the articular and febrile disturbance are lessened, 
and till an alkaline condition of the urine is established as 
soon as possible. Liquor potassse in 3 ss. doses may also 



RHEUMATISM, ACUTE. 337 

be given to the extent of 3 ili- to 3 vi. in twenty-four 
hours (Parkes). Brocklesby is the earliest authority for 
the use of large doses of nitre in the treatment of acute 
rheumatism. He enjoined, for a diluting drink, water- 
gruel boiled smooth, in each quart of which he dissolved 
two drachms of nitre, with or without sugar. He often thus 
prevailed on soldiers to take ten drachms or more of nitre in 
twenty-four hours. Dr. Garrod speaks well of the combina- 
tion of quinine with the alkaline treatment after ten years' 
trial. It is simply following out the treatment by bark (un- 
practical, from the large doses required) recommended by 
Fothergill, Morton, and Haygarth. Five to ten grains of 
sulphate of quinine are to be given two or three times a day. 
The alkaline and saline treatment of rheumatism as the basis 
of operation seems the most rational ; for it has been demon- 
strated that in cases of acute rheumatism there is an abso- 
lute deficiency of the saline ingredients of the blood ; and 
while there is also a liability to fibrinous exudation, the ten- 
dency of saline remedies is to suspend the separation of fi- 
brine (Stevens). The treatment which has saline remedies 
for its basis thus contributes to restore the balance of the sa- 
line ingredients in the blood, and controls the tendency to 
fibrinous deposition. The progress of inflammatory action 
being thus retarded, time is gained for other remedies to ef- 
fect the diminution of the excess of nbrine present in the 
blood, as well as the destruction of the rheumatic element, 
whatever that may be. On the other hand, however, the pa- 
tient is often left weak and anaemic to a marked degree by 
the use of alkalies ; and also, that when heart complications 
do come on under alkalies they are more troublesome, the 
effusion of pericarditis is often very large in amount, and 
there is a greater tendency to carditis. Thus alkalies, while 
they shorten the disease, do not always prevent complications, 
and they debilitate the patient. Cases treated by alkaline 
instead of neutral salt are also slow in convalescence, the 
patients being weak and pallid for some time afterwards. 
The experience of Dr. Reginald Southey is also against the 
alkaline treatment, especially in the relapsing cases. The 
alkaline treatment or mint-water is, however, equally well 
adapted for the acute continued form ; but alkalies, unless 
pushed to full and frequent doses, are wholly useless in re- 
lieving pain ; and in such large doses as half a drachm or a 
drachm every two or three hours, they quickly reduce the 
Strength, and render the patient extremely anaemic. They 



33% RHEUMATISM, ACUTE. 

thus retard convalescence not inconsiderably. {Bartholo- 
mew' 's Hospital Report). 

In 1869, Dr. Russell Reynolds reported, in the Brit. Med. 
Journ., cases of rheumatic fever treated by the tincture of 
the perchloride of iron, in doses varying from 15 minims to 
a drachm every four hours, with or without 20 to 30 minims 
of glycerine, and spirits of chloroform. In Brit. Med. Journ., 
of Oct. 2, 1875, he again gave a summary of results in a 
series of sixty-five cases, in which the relief of pain was often 
marked and early. In more than half the cases the pain was 
gone by the tenth day ; in 22 per cent, all pain had gone by 
the fifth day. The pulse sometimes fell from 120 to 40 in 
two days ; and, in several cases, Dr. Reynolds observed a 
remarkable diminution in the frequency of the pulse, at and 
after the time at which temperature had become normal, 
namely — 40, 30, and even 28 ; but regular in rhythm and in 
force, the patient feeling neither pain nor faintness. The 
temperature became normal by the fifth day in 36 per cent. ; 
and in severe cases before the tenth day in 50 per cent. ; in 
moderate and slight cases in 71 per cent. Heart disease was 
present in 48.1 per cent.; but no distinction is made between 
those cases in which it existed before, and those in which it 
came on under treatment. In twenty-three cases treated 
with iron in University College Hospital in 1875, the heart 
was affected in 30.4 per cent. — a large proportion when com- 
pared with those cases of Dr. Dickinson's treated by alka- 
lies, where the percentage was only 2.1. As to duration of 
the cases also, the cases treated by iron do not compare fa- 
vorably with those treated by alkalies by Dr. Garrod, where 
the average duration of the whole number of cases was six 
to seven days. Dr. Samuel S. Dyer of Ringwood has also 
given the treatment by the tincture of perchloride of iron an 
extended trial, and writes as to the satisfactory nature of the 
result (Brit. Med. Journ., May 6, 1876, p. 563). Quinine 
has been largely used in France — in large doses^-from 15 to 
90 grains in the twenty-four hours. The pulse and temper- 
ature rapidly fell ; the joints were quickly relieved ; and the 
heart was seldom implicated. Combined with the alkaline 
treatment Dr. Garrod has found quinine more efficacious 
than either alone — there being less tendency to relapse ; and 
the fever leaves the patient in a much more satisfactory con- 
dition. Salicine, salicylic acid, and salicylate of soda have 
all been recently and largely used in the treatment of acute 
rheumatism ; given in doses of gr. x. to gr. xx. at intervals 



RHEUMATISM, ACUTE. 339 

of from one to three hours, and in larger doses ot gr. xxx. 
every hour. Under all of these remedies the average dura- 
tion of the fever has been remarkably shortened — to 4.9 days 
under salicine, and 4.1 days under the acid — an advantage 
of from one to three days over the results of the alkaline 
treatment , and in comparison with the tincture of iron 
treatment, in which the temperature became normal in half 
the cases in ten days, under salicylic acid it became normal 
in half the cases in three days. The duration of rheumatic 
fever has, therefore, been shorter under these remedies than 
it has been under any other plan of treatment. But there 
is no evidence that either of these are specific remedies, for 
they do not cut short the disease ; nor prevent relapses when 
under their influence ; nor do they ward off complications. 
They seem rather to act by reducing temperature as they do 
in other febrile conditions, and they lessen the chance of 
complications in the same proportion as they shorten the 
disease (Dr. Markham Skerritt). The observations of Fur- 
bringer, Reiss, Fischer, Strieker, and others have established 
the fact that these remedies possess a remarkable power of 
lowering the abnormally high temperatures in febrile dis- 
eases. In Dr. Strieker's experience of the drugs in acute 
rheumatism, salicylic acid may be given in hourly doses of 
from grains vii. to xv. without injury to the human system ; 
and for a longer time to young and vigorous subjects than 
to the old and feeble, as toxic symptoms appear sooner in 
the latter than in the former. These toxic symptoms are of 
various degrees — such as, noises in the ears, difficulty of 
hearing, and perspiration, which, when they appear, con- 
traindicate the further use of the remedy. 

"In an interesting paper in the Lancet of 4th and nth of 
March, by Dr. T. Maclagan, recently of Dundee, on the 
treatment of acute rheumatism by salicine, the author relates 
seven cases of acute and subacute, and one of chronic rheu- 
matism, treated with this remedy, and gives the following 
conclusions as the result of his experience : — (1.) We have 
in salicine a valuable remedy in the treatment of acute rheu- 
matism. (2.) The more acute the case, the more marked 
the benefit produced. (3.) In acute cases, its beneficial ac- 
tion is generally apparent within twenty-four, always within 
forty-eight, hours of its administration in sufficient dose. (4.) 
Given thus at the commencement of the attack, it seems 
sometimes to arrest the course of the malady as effectively 
as quinine cures an ague, or ipecacuanha a dysentery. (5.) 



34° RHEUMATISM, ACUTE. 

The relief of pain is always one ot the earliest effects pro- 
duced. (6.) In acute cases, relief of pain and a fall of tem- 
perature generally occur simultaneously. (7.) In subacute 
cases, the pain is sometimes decidedly relieved before the 
temperature begins to fall ; this is especially the case when, 
as is frequently observed in those of nervous temperament, 
the pain is proportionally greater than the abnormal rise of 
temperature. (8.) In chronic rheumatism, salicine some- 
times does good where other remedies fail ; but it also some- 
times fails where others do good. These conclusions, it will 
be seen, agree closely with those arrived at by Strieker and 
Reiss with regard to salicylic acid. The dose of salicine 
used by Dr. Maclagan was from ten to thirty grains every two 
three, or four hours ; fifteen grains being an average dose." 

As to salicylate of soda, Dr. R. Southey gives fifteen 
grain doses every two hours till sixty grains are taken, and 
then continues with fifteen grain doses every four hours, to 
keep up the effect of the drug ; and if pericarditis is present 
he adds five drops of liq. opii. sedativ. with each dose. His 
experience of the perchloride of iron, as recommended by 
Dr. R. Reynolds, is not favorable. In the acute continued 
cases it has been associated too frequently with hyperpy- 
rexia to regard it as altogether free from danger ; and in the 
relapsing forms, its administration neither shortened the cases 
nor prevented relapses. These relapsing cases of rheuma- 
tism may be kept on salicylate of soda very well for the first 
seven days ; but the opportunity of the spontaneous remis- 
sion which then generally takes place, and is indicated by the 
thermometer and the patient's own sensations, should be 
seized to shake the periodicity of the complaint. This qui- 
nine has the power of doing, given in the proper doses, as in 
ague, and at the proper date. Dr. Southey gives two ten- 
grain doses at two hours' interval, between five and seven 
p. m., on the evening of the seventh day, and repeats the dose 
on the evening of the ninth day again. The natural relapse 
is then postponed, and the patient may be permitted better 
nourishment, and given a little pepsine and acid with his din- 
ner to ensure its better digestion. Should no relapse happen, 
again on the fourteenth and sixteenth days full doses of qui- 
nine should be given ; but it is not till the thirty-second day 
is past that all risk of a relapse is over. During convales- 
cence, although the patients are anaemic, Dr. Southey does not 
recommend iron, as the mineral acids and tincture of nux 
vomica promote appetite and digestion far better. Quinine 



RHEUMATISM, ACUTE. 34I 

and iodide of potassium has long been a favorite draught 
of his in treating the anaemic relapsing forms. Two grains 
of quinine are combined in it with five of iodide of potas- 
sium, to be taken every four or six hours after the fourteenth 
day (St. Bartholomew's Hospital Report, Vol. XIV., 1878, p. 
22). Hyperpyrexia may occur suddenly and rapidly in acute 
rheumatism, as in other diseases. The temperature may 
rapidly rise to a height incompatible with life, with evidence 
of profound nervous disturbance ; and usually by the dis- 
appearance of pain from the joints. Such hyperpyrexyia 
has supervened under all sorts of treatment. The ex- 
tremest vigilance on every one entrusted with the care 
of the patient must be inculcated ; and on the appear- 
ance of anything strange in the aspect or demeanor, to 
use the thermometer assiduously ; and, if ever it rose to 105 
Fahr., to send at once for the physician (Dr. H. Thomson). 
Treatment directed simply to the reduction of temperature 
may save the life of the patient. A temperature in rheu- 
matic fever above 106.5 ° Fahr. has hitherto been invariably 
fatal ; spontaneous recovery has never been known to occiii 
when the temperature has passed 106.5 ° Fahr. ; but death 
has occurred before this temperature has been reached — at 
105. 8° and 106 . Hence the commencement of active treat- 
ment by the cold bath ought not to be delayed when such a 
temperature has been reached. If left alone, the patient 
must die ; and the only treatment which has succeeded with 
such cases has been the effectual, external application of cold, 
by the bath, at a temperature of 90 or 95 ° Fahr. in the first 
instance ; gradually reduced by the addition of cold water 
to jo Q Fahr., or even lower in some cases. As far as the bath 
is concerned we must take the thermometer for our guide. 

" It is important to remember that the bath should be pre- 
pared and everything got ready before this ; for the final 
rise of temperature is often very rapid — 5.5 ° in an hour and 
a quarter — from 104 to 109.5 °, and the patient may die be- 
fore the treatment can be applied. There is another practi- 
cal point to be borne in mind — that there is almost always a 
considerable fall of temperature after the patient is removed 
from the bath, so that it is not cafe to bring the temperature 
down to the normal in the bath. I remember, in the early 
days of this treatment, how a friend of mine reduced the 
temperature of a rheumatic patient to normal in the bath, 
and, to his consternation, found it would not stop there, but 
kept going down till it reached 93.2 ; there it was fortunately 



342 RHEUMATISM, ACUTE, 

brought to a stand. The amount of this subsequent fall 
varies, but the average may probably be safely taken as 4 . 
In accordance with this, I removed the patient from the bath 
when the temperature was 102 °, and the subsequent fall, oc- 
curring in the next ten minutes, was exactly 4 , bringing the 
temperature down to 98° " (Dr. Markham Skerritt). 

So singularly calming is the bath, even when there is no 
great exaltation of the body heat, that it may be administered 
as a simple palliative in all exacerbations of delirium and 
restlessness, although the heat may have fallen far below its 
maximum intensity, even to 102 Fahr. 

External topical applications are efficient aids in treatment. 
Warm anodyne fomentations are always employed with ad- 
vantage ; and of all applications a mixed alkaline and opiate 
solution, applied as a fomentation, is the most powerful in 
allaying pain. The solution so highly recommended by the 
late Dr. Fuller for this purpose, is composed of an ounce of 
the carbonate of potash dissolved in a pint of the decoction 
of poppies or of rose water, to which six drachms of Bat- 
tley's solution (Liquor sedativus) is added, or common tinc- 
ture of opium, which is less expensive and equally efficient 
as an external application, but less strong. Chloroform and 
belladonna liniment (as recommended by the late Dr. Sibson) 
is an excellent pain-relieving local application in either the 
acute or relapsing form of the disease. If the hands, elbows, 
knees, or feet are the seat of inflammation, gloves or caps 
are made of the spongiopiline to fit these parts ; if a greater 
extent of surface be involved, a portion of the spongiopiline 
is cut large enough to envelop the entire surface. The spongy 
surface of this epithem is first moistened freely with water, 
and any superabundant fluid squeezed from it, so that the 
linen or bed of the patient may not be unnecessarily wetted. 
Nitrate of potash, or the salt to be employed, in powder, is 
then freely and plentifully sprinkled over the moistened sur- 
face, or rubbed in, to secure its solution and the thorough 
impregnation of the epithem ; it is then applied to the in- 
flamed part, and lightly secured by a roller. Nothing fur- 
ther is required than once in about six hours to remoisten 
the spongy surface ; fresh addition of nitre is never required, 
if sufficient quantity has been used in the first instance. The 
salt in powder is hence better than a saturated solution, 
which nurses seldom succeed in making (Basham, Med.-Chir. 
Trans., Vol. XXXII. , p. 10). Alkaline baths are recom- 
mended by Dr. Austin Flint. Two pounds of the bicar- 



RHEUMATISM. \CUTE 343 

bortate of potass and one pound of the nitrate of potass are 
to be dissolved in water, at a temperature of ioo° or 99 ° 
Fahr. ; and the patient ought to go into the bath at a tem- 
perature of 98 or 98.5 ° Fahr., and remain for not longer than 
ten minutes. A tepid bath at 98 or 96 Fahr., into which 
the patient can be dipped suspended on a sheet, and lifted 
similarly back to bed, comforts them and secures their 
cleanliness (Dr. R. Southey). Hot air, or vapor baths, differ- 
ent forms of cold bath, the hot blanket pack bath (as ad- 
vocated by Dr. T. S. Dow, see in Brit. Med. Joum., 1875, 
p. 40), or sponging the skin with cold or tepid water, are 
each in turn methods of treatment which have given relief ; 
but baths ought never to be employed if the skin is acting 
freely ; only if it is hot, dry, and burning, its action may be 
successfully stimulated by means of some of these baths. 

In contradistinction to the principle of cure now laid down, 
and which has been called the method of neutralization, Dr. 
Herbert Davies, Physician to the London Hospital, has re- 
cently advocated a method by elimination, originally recom- 
mended by Dr. Dechilly, of Vancouleurs, in France, in a 
Memoir to the Academy of Medicine, in 1850 {Bui. de 
I Acad, de Med., t. xv.), as a safe and rapid mode of combat- 
ing rheumatic fever. For this purpose his treatment is ab- 
solutely and entirely local, and consists of free blistering 
only. Believing that the virus localizes itself for a time in 
the inflamed joints ? and that the intensity of the local in- 
flammation is a measure of the amount of virus collected, he 
orders blisters varying in width, but of considerable size, 
according to the locality, to be appiled round each limb, and 
in close proximity to the parts inflamed. Thus he affords, 
through the serous discharge from the blistered surface, a 
ready means of exit for the virus. The blisters are to be 
applied near to, but not upon every joint inflamed, at the 
very height of the inflammatory stage, even when the local 
pains are the most severe, and the constitutional disturbance 
the greatest. Dr. Dechilly enveloped the whole joint in a 
large blister, followed by others, according as joints became 
affected. Dr. Jeaffreson, of St. Bartholomew's, and Dr. 
Greenalgh, of the Middlesex Hospital, report favorably as to 
the results of Dr. Davies' method of treatment of acute 
articular rheumatism. So also does Dr. Thomas B. Peacock, 
of St. Thomas' Hospital {Brit. Med. Journ., Jan. 18, 1873). 
It has been tried in France also, and reported on favorably 
by Dr. Laseque, of the Necker Hospital in Paris {Arch. Gen. 



344 RHEUMATISM, ACUTE. 

de Med., Nov., 1865). The success of the plan is said to de- 
pend entirely upon the blisters being applied and allowed to 
remain until they have thoroughly acted. Linseed-meal 
poultices subsequently applied will be found highly service- 
able in promoting a sufficient flow of serum. The blisters 
should be put entirely round the affected limb ; and when 
the knees are the joints which suffer, the blisters should be 
cut at least three inches wide. If this method of treatment 
be adopted, no medicine ought to be given beyond an occa- 
sional purge, and no advantage results from combining the 
alkaline or neutralization system of treatment with that by 
blisters, or the method by local elimination. If the two 
methods are combined, the period of convalescence is pro- 
tracted. In some few cases, however, Dr. Peacock is of 
opinion that constitutional treatment ought to be freely used 
in combination with the blistering. In other cases it is of 
advantage to combine the blister treatment with such tonics 
as quinine and iron. In the practice of Dr. R. Southey, of 
St. Bartholomew's, London, painting the affected parts in the 
acute continued form with a mixture of equal parts of liniment 
of iodine and tincture of iodine has appeared to procure all 
the benefit advocated by Dr. Davies for his blister treatment. 
That the poison is really thrown out by the blister method 
of treatment is deduced as well from the rapid and perma- 
nent relief resulting from the local treatment as from the 
neutral and even alkaline condition of the urine, which is a 
usual and early result of the treatment, as well as a rapid 
diminution in the force and frequency of the pulse {London 
Hospital Clinical Reports). 

The diet of the patient, in acute rheumatism, should be 
strictly limited to slops, such as arrow-root, beef-tea (Liebig's 
Extract of Flesh), milk and lime-water, or milk made warm, 
to which a little carbonate of soda, nitrate of potash, or bi- 
carbonate of potash is added ; light puddings, to which 
sherry or brandy may be added, if depression exist ; and 
even in many chronic cases it is desirable to limit the diet to 
puddings and white fish. To obviate the great drain upon 
the system, it is necessary, however, that the rheumatic pa- 
tient be better fed than in cases of idiopathic inflammation. 
Beef-tea and jellies may be given, and strong coffee might 
also be administered frequently, on the same principle that 
it has been given in typhus fever by Dr. Parkes, following up 
the indications obtained from the physiological action of 
that beverage as expounded by Lehmann. 



RHEUMATIC ARTHRITIS—RICKETS. 345 

The nature and treatment of the local complication, such 
as pericarditis, will be considered separately ; but in addi- 
tion to the alkaline remedies, which have an undoubted influ- 
ence in shortening the duration of the illness, the bedding in 
blankets, is a most important measure for preventing the 
cardiac affection, especially in cold weather and in cold 
climates. 

Rheumatic Arthritis — See Osteo- Arthritis, Chronic. 

Rheumatism, Chronic. — Definition. — Chronic pain, 
stiffness, and swelling of various joints. 

The Treatment of chronic rheumatism does not differ in its 
general details from that of acute rheumatism. Decoction 
of cinchona, preparations of guaiacum, with alkalies and col- 
chicum, are the best remedies after the action of such search- 
ing evacuants as calomel and jalap have removed morbid 
accumulations, and improved intestinal secretions. The va- 
rious forms of the so-called " Chelsea Pensioner," compris- 
ing guaiacum and sulphur, the composition of which is given 
under " Rheumatism, Acute," are of great service. Iodide 
of potassium is also of great benefit in the arthritic forms of 
chronic rheumatism, combined or not with preparations of 
aconite and colchicum. Warmth of flannel and the warmth 
of bed, with free perspiration, generally tends to mitigate and 
shorted the severity of the paroxysms of chronic rheumatism. 

Rheumatism, Gonorrhceal — See Gonorrheal Rhemna- 
tism. 

Rheumatism, Muscular — See Muscular Rheumatism, 

Rickets. — Definition — A constitutional disease of early 
childhood, characterized by a cachexia which precedes for 
several weeks or months a peculiar lesion of the osseous sys- 
tem, manifested by curvature of the shafts of the long bones 
and enlargement of their cancellous extremities. The growth 
of the bones is characterized by irregularity, by non-solidifi- 
tion of their growing layers, and by the progressive forma- 
tion of medullary cavities in the old bone, thus rendering 
the body laminae thin and brittle (Virchow). Some of the 
solid visceral organs also exhibit peculiar lesions, such as in 
the spleen and liver, where there is generally lardaceous dis- 
ease. 

Treatment. — Ventilation of the room in which the child 
lives is of first importance. Milk diluted with lime-water 
(about a fourth part), and a teaspoonful of cream added, is 
the best of food, or the Swiss preserved milk. Sugar ought 



34& RINGWORM-— SCABIES. 

not to be added to the milk. Liebig's Food for Children, 
or Valentin's flesh juice, " Maltine," Parrish's Chemical 
Food, and Trommer's Extract of Malt, are all valuable 
agents in the dietary. About once a week a dose of rhu- 
barb, soda, and calumba, in equal parts, should be given, 
followed next day by a teaspoonful or more of castor- oil. 
Prepared chalk and soda may also be given twice or thrice 
a day, with or without rhubarb and calumba (see under 
treatment of Scrofula). When the febrile disturbance is 
subdued, the child should live as much as possible in the 
open air. Vinum ferri ought then to be given in the follow- 
ing formula? fy. Vin. ferri f 3 i- 3 ii- ; quiniae sulph., gr. i., 
acid sulph. dil. m i.-ii. This form is especially useful when 
the skin is flabby, covered with perspiration, and anaemia 
well marked. Or small doses of the syrup of the phosphates 
of iron, quinine, and strychnia, or syrup of the phosphate of 
iron and lime, may be given along with the food, or just be- 
fore meals. Cod-liver oil is of essential service; but the 
stools ought to be examined daily; and if any of the oil 
passes by stool its dose ought to be diminished, or its ad- 
ministration suspended for a time. (Sir William Jenner, 
The Medical Times of i860, Vol. I). 

Ringworm — See Tinea Tonsurans. 

Rothelll — See Measles. German. 

Rubeola — See Measles. 

Saturnism — See Lead Palsy. 

Scabies. — Definition. — Lesions consisting of an eruption 
of distinct slightly acuminated papules or vesicles, accom- 
panied with constant itching, due to the irritation caused by 
the burrowing underneath the epidermis of a female Acarus 
(" Sarcoptes scabei"), for the purpose of depositing hei 
eggs. 

IVeatment. — Such applications are to be made to the skin 
that, while tending to kill the Acari, they will not increase 
the irritation of the dermis; and if the Acari are thus de- 
stroyed, the eruptions will in general subside in due course. 
If much irritation of the skin prevails, warm baths are to be 
prescribed, and opium may be given internally. In healthy 
adults the whole body of the patient ought first of all to be 
thoroughly scrubbed over with good black (soft) soap, and 
the process continued for at least half an hour. The patient 



scabies. 347 

should then get into a warm bath, in which he should re- 
main for another half hour. Having thus washed and dried 
himself thoroughly, he is to rub himself over with the fol- 
lowing ointment: 

I£. Subcarbonatis Potassae, 3i.; Sulphuris, 3ii-; Axun- 
giae, § xii. ; misce. 

Next morning a warm bath is to be taken to clean the 
surface of the body from the remains of the anointing of the 
previous night. The cure ought now to be complete, so far 
as the destruction of the Acari is concerned (Hardy, Hel- 
merich, Anderson). The genuine pomade of Helmerich is 
one-third stronger than that which has been just quoted 
from Dr. Anderson. The potash in the black soap and oint- 
ment acts as a solvent of the epidermis, and thus allows the 
sulphur to come into more immediate contact with the 
Acarus. A warm bath and plenty of hot water ablution 
completes the cleansing process. The treatment may, how- 
ever, be inapplicable to children, females, and men with 
delicate skins or constitutional affections of the skin. In 
them, although the principle of treatment is the same, the 
process of cure must be more slowly conducted by less pow- 
erfully irritant substances. The patient having cleansed 
himself thoroughly in a warm bath, with ordinary vellow 
soap, the following lotion may be applied: 

3* Calcis, f ss.; Sulphuris, § i. ; Aquae, | viii. These 
ingredients are to be boiled and stirred constantly till a 
homogeneous mixture is oroduced, which is to be strained 
through a sieve. 

These ingredients ought to produce a quantity more than 
sufficient for one person, and should be rubbed into the 
skin, not too roughly, every night for several evenings. The 
cases of scabies in the Belgian army are treated by this lotion 
(Velminskz, Anderson). When the person affected is pre- 
disposed to exematous eruDtions, the following application 
is recommended: 

]J. Sulphuris, Olei Fagi, a a 3 vi.; Saponis Viridis, Axun- 
giae, a a lbj.; Cretae, 3 iv.; misce. 

This ointment should be well rubbed in, after the skin has 
been prepared for it by the use of the warm bath and cleans- 
ing the body with common yellow soap. The potash in the 
black soap of the ointment acts as already stated, the chalk 
tends to remove the epidermis mechanically, the tar coun- 
teracts the tendency to eczema, and the sulphur destroys the 
Acari. The ointment ought to be left on overnight 



348 SCARLET FEVER, 

(if the skin is not too irritable), and should be washed off in 
the morning (Wilkinson, Hebra, Anderson). Specific print- 
ed directions should be given to each patient; and cards are 
useful for this purpose, similar to those in use in the Dis- 
pensary for Skin Diseases in Glasgow. The following are 
the directions printed on each card, which is given to each 
patient along with the quantity of ointment required: 

" 1st. Scrub the whole of your body (except the head) as 
firmly as possible, without hurting yourself, with black soap 
and water. 

" 2nd. Sit in a hot bath for twenty minutes, or if you can- 
not get a bath, wash yourself with hot water thoroughly. 

" 3rd. Rub some of the ointment firmly into the skin of 
the whole body (except the head) for twenty minutes. Let 
the ointment remain on the body all night. 

" Repeat these processes every night for three nights, and 
then return to the dispensary. 

" Besides, put all your washing clothes into boiling water, 
and iron all your other clothes thoroughly with a hot iron." 

The ordinary compound sulphur ointment of the pharma- 
copoeia is also an efficient remedy. The cure being com- 
plete so far as the person is concerned, care must be taken 
to destroy the Acarus and its eggs which may be amongst 
the clothes of the patient. For this purpose they should be 
exposed to hot air at the temperature of at least 150° Fahr., 
or boiled in water, or exposed to the action of sulphur by 
steaming them amongst sulphur vapors. If such methods 
are systematically carried out, itch cases ought never to oc- 
cupy hospital beds, either in civil or in military life. 

Scarlet Fever. — Definition — A specific febrile disease, 
the product of of a specific contagion, which is reproduced 
during the progress of the affection. The duration of the 
incubation stage may be only a few hours ; in a large pro- 
portion of cases it probably does not exceed forty-eight 
hours, and very rarely exceeds seven days (Murchison). On 
the second day of the illness, or sometimes later, a scarlet 
efflorescence appears on the fauces and pharynx, and on the 
neck and face, which spreads over the whole body, and 
commonly terminates in desquamation from the fifth to the 
seventn day. The fever is accompanied with an affection 
of the kidneys, with albuminuria, often with severe disease 
of the throat, or lymphatic glands of the neck, and is some- 
times followed by dropsy and other lesions. The disease 



SCARLET FEVER. 349 

runs a definite course, and, as a rule, occurs only once dur- 
ing life. 

Treat?neni. — Scarlet fever being accompanied by appar- 
ently inflammatory symptoms, the practice of bleeding has 
prevailed on the first breaking out of the disease in all coun- 
tries, and with the most disastrous results (Willan) ; so that 
Morton speaks of witnessing 300 deaths from scarlatina in a 
week. This practice prevailed down to the time of Huxham, 
who abandoned it, and introduced a treatment by bark. 
Thus an entirely opposite system of treatment has been 
gradually introduced, and the records of medicine enable us 
to state the results of these opposite modes : — " Of cases 
treated at the Foundling Hospital by bleeding in 1786, and 
of cases treated at the London Fever Hospital in 1829, in 
the same manner, one in six died after bleeding, while only 
one in twenty-two died after a directly opposite mode of 
treatment. The conclusion was inevitable, that the chances 
of recovery are diminished by the practice of bleeding, 
nearly in the ratio of four to one, as compared with the 
chances of recovery supposing the patient not to have been 
bled. 

It should be laid down as a maxim, that in cases of scar- 
let fever medical advice ought always to be had recourse to 
as early as possible ; for the worst cases we meet with are 
those in which the disease has, from its apparently mild 
character, been left to itself. In the mildest form of the dis- 
ease it is sufficient to confine the patient to the house ; to en- 
join strictly a milk diet ; to regulate the bowels ; and, above 
all things, to avoid the nimia diligentia medicorum. Any 
active interference with the normal course of the disease is 
to be avoided. The sick room ought to be kept at a uni- 
form temperature, and not exceed 6o° to 65 ° Fahr. The 
patient must not be overladen with bedclothes ; and the skin 
ought to be sponged over twice daily with tepid water, dif- 
ferent parts being exposed in succession, and carefully dried 
with soft cloths. The water should be used without soap, 
but with an abundance of Condy's fluid in it. As much 
fresh air as possible should be admitted to the room. The 
best drink is water, pure and cold ; while soups of meat, 
Liebig's extract of meat, stewed fruit, and milk, ought to 
form the staple diet. Constipation is to be overcome by en- 
emata of tepid water and salt, avoiding purgation by medi- 
cine. In the simpler cases of scarlet fever such manage- 
ment is sufficient, 



350 SCARLET FEVER. 

In the cases commencing with much sickness and general 
disturbance, a gentle emetic at the outset is believed to 
modify the future course of the disease. Ipecacuanha, with or 
without tartar emetic, is the best form for administration ; 
and half an ounce of castor oil ought to be given after the 
action of the emetic has ceased. Looking to the morbid 
condition of the blood, and to the tendency which exists to 
the deposition of fibrine in the right cavities of the heart, 
small doses of carbonate of ammonia (three to seven grains), 
administered every hour, or every three hours, as soon as the 
symptoms are decided, have been recommended (Peart, 
Witt, Richardson). Or, the liquor ammoniae acetatis may be 
used with an excess of ammonia, to the amount of from 
three to five drops of liquor ammoniae added to two fluid 
drachms of the former in a liberal quantity of distilled water 
(Richardson). It is important to administer these medicines 
in small and frequently repeated doses ; and, if possible, let 
the remedy be taken as a drink ; and as such chlorate of 
potash may be used freely. 

The treatment of the milder forms of the fever, when the 
tonsils are considerably enlarged, is, first, to tranquillize the 
stomach and allay its perverted action when vomiting exists, 
either by small doses of the sulphate of magnesia, or by ef- 
fervescing salines — medicines which, according to the state 
of*the bowels, may be given every four or every six hours. 
The gum resin of guaiacum is of great service in subduing 
the cynanche tonsillaris, and may be prescribed in the fol- 
lowing formula : — 

$. Magnes. Sulp., 3 vi. ; solve in Aqua, S viii. ; adde 
Pulv. Guaiaci, 3 iss. ; Pulv. g. Tragacanth. co., 2> ij. ; misce 
bene. One-sixth part of this mixture may be given every 
four hours, till the bowels are freely moved. 

As soon as this object is effected, and it is ascertained that 
the tonsils are still greatly enlarged and swollen, it may be 
necessary to relieve them, if no adynamic symptoms exist, by 
the application of six to twelve leeches about the angles of 
the jaw ; and the bleeding may be further encouraged by the 
application of a poultice. The trifling loss of blood thus 
sustained does not impair the general strength of the patient, 
if it is done sufficiently early, while it greatly reduces the 
swelling of the tonsils, and may prevent them becoming per- 
manently enlarged. Another advantage is gained by the ap- 
plication of leeches to the throat — namely, that they relieve 
the affection of the head symptoms. If the tonsils are thus 



SCARLET FEVER. 35 1 

relieved, the fever ought to be permitted to run its course 
uninfluenced by medicine, beyond the occasional administra- 
tion of the saline draught and ice, or the inhalation of steam. 
Such remedies should be persevered in till the disappearance 
of the eruption, and till the healthy granulations of the throat, 
and the decline of the fever, give evidence of a state of con- 
valescence. At this point some mild tonic medicine is de- 
sirable. With children under ten years of age, however, it is 
better to trust to the soothing effects of warm poultices round 
the throat, and inhalation of steam, than weaken the child by 
loss of blood. 

The severe forms of the disease, characterized by the less 
swollen state of the tonsils, and by their being more livid and 
gorged with blood ; by ulceration being deep and spreading ; 
by the slough being fouler than in the milder varieties ; and 
by the greater tendency of the inflamed parts to run into 
mortification — the necessity of adopting a more stimulating 
plan of treatment, and one more calculated to support the 
powers of the constitution, is manifest, and experience has 
shown its good results. Nourishment in the form of soups, 
meat extracts, or milk, must be given in small quantities fre- 
quently repeated, in proportion to the prostration of the pa- 
tient. The administration of wine, and of the " extractum 
carnis Liebigii" should therefore be the basis of the treat- 
ment of such cases. The quantity of wine for an adult may 
be from four to six ounces in twenty-four hours, and for a 
child about half that quantity or less. The wine should be 
taken in small quantities, mixed with two-thirds water ; or it 
may be given with sago, arrow-root, jellies, or other demul- 
cent food. The earlier the wine is given in the disease the 
better, whether delirium does or does not exist ; regardless, 
also, as to whether the tongue is moist and white, or brown 
and dry ; and it should be continued till the patient is con- 
valescent. Liebig's extract of flesh may be given like beef- 
tea, as a drink. While pursuing this plan, it is necessary that 
the patient's bowels should be attended. In cases more 
severe, brandy may be required, or carbonate of ammonia in 
liquor cinchonas ; and iron in some form should be given in 
frequently repeated small doses, either with the nourishment 
or with the medicines already mentioned ; or it may be com- 
bined with quinine and aromatic sulphuric acid. 

If an emetic is first given it may be proper, before adopt- 
ing any special continuous mode of treatment, to follow its 
action by a dose of oalomel as a purgative, and this especially 



352 SCARLET FEVER. 

with robust children, to be followed in six or seven hours by 
castor-oil or magnesia ; and the bowels are ever afterwards to 
be kept open by remedies suited to the state of the patient 
and the nature of the disease. The following are the princi- 
pal indications which must guide the treatment : — If there is 
much excitement of the system, in an otherwise strong, well- 
grown subject, depleting cathartics are to be given ; if nausea 
and vomiting prevail, a seidlitz powder is of service ; if the 
discharges from the rectum are acrid and acid, with acidity 
of the stomach, magnesia is preferable ■ if there is abdominal 
pain, castor-oil with opium (Wood). 

Again, when the synovial membranes inflame, and the 
joints become enlarged and swollen, all stimuli should be 
withdrawn, and a moderate action of the bowels should be 
kept up by means of the sulphate of magnesia, with camphor 
mixture, or with carbonate of ammonia, or quinine in infu- 
sions of chiretta or of gentian ; and if pain be severe, some 
sedative should be added, as the tincture of hyoscyamus in a 
dose of fifteen minims. 

The more formidable affection in scarlet fever is dropsy, 
sometimes with effusion into the pleurae. Bleeding by leeches 
over the region of the kidneys is then of service, in cases 
which will tolerate this remedy, especially if oedema appears 
in the face, and is accompanied by headache, — from two to 
four ounces in the child, and from four to eight ounces in 
the adult may be taken. The good results of cupping (even 
of dry cupping) are also very remarkable ; and of continu- 
ously hot poultices over the lumbar region, with or without 
the addition of digitalis. By these means renal conges- 
tion is relieved, and the urine becomes more copious 
and less albuminous. Hot air or vapor baths, to ex- 
cite cutaneous action, may be also of service, combined with 
diluent drinks. Diaphoretic doses of antimony, and moder- 
ate but not severe purging, may be had recourse to, if ana- 
sarca makes progress. The compound powder of jalap, or 
the bitartrate of potash alone in drachm doses, three times a 
day, are then most useful, especially as an electuary, in which 
the cream of tartar is mixed with nearly an equal quantity of 
honey, treacle, or marmalade, or syrup of ginger, and flavored 
if necessary, with a few drops of peppermint oil. Squills and 
digitalis are also of special service as diuretics till the urine 
resumes its natural appearance. In young children (of five 
years of age and under) digitalis in scarlatinal dropsy is al- 
most always beneficial, given in combination with perchloride 



SCARLET FEVER. 353 

of iron. It is followed by a steady increase in the quantity 
of urine, with a corresponding subsidence of effusion. Five 
minims of the tincture of the perchloride of iron, with a 
drachm and a half of the infusion of digitalis in anis or cara- 
way water, may be given three times a day, and continued 
without intermission for fourteen days. Children bear such 
doses, and larger ones, of digitalis remarkably well ; and the 
infusion in preference to the tincture, with iron and a nutri- 
tious diet (Cheadle, Brit. Med. Joum., November 23, 1872). 
The muriated tincture has the best reputation. The iodide 
of potassium in small doses is also useful ; and with this lat- 
ter remedy the syrup of the iodide of iron may be combined, 
if it is desirable to continue the chalybeate ; or syrup of the 
phosphate of iron, combined with glycerine in drachm doses 
of the combination. 

Gargles are unnecessary for children, for they cannot gar-* 
gle; but they are of the greatest service, especially the de- 
odorizing gargles or washes, when the patient can be taught 
to use them. A weak solution of chloride of lime, or of 
chlorine water, or of Condy's fluid, or permanganate of 
potash, is well adapted for such a purpose. The following 
is recommended as a most efiectual gargle : 

Solution of peroxide of hydrogen (containing ten volumes 
of oxygen), six ounces; tincture of myrrh, an ounce; rose 
water, five ounces (Richardson). 

This gargle may be used at pleasure; it is refreshing to 
the patient, and removes the offensive secretions. With 
young children, who are unable to use a gargle, the throat 
may be washed out, by holding the little patient with the face 
downwards, and then pumping the solution over the surface 
of the fauces through a bit of gum catheter from a double- 
acting india-rubber bag (Richardson, Clinical Essays, p. 
no). As an invariable routine practice, Dr. W. T. Gaird- 
ner strongly recommends that " the steam of hot water should 
be inhaled from the beginning to the end of the fever, as 
long at least as the throat is sore." In slight affections it is 
sufficient to employ infusion of linseed in water, acidulated 
with nitro-muriatic acid, weak solutions of alum, nitre, or 
common salt. When membranous diphtheritic patches are 
observed on the fauces, and the color of the mucous mem- 
brane is of a dark-red, capsicum infusion, or powdered red 
pepper, is an excellent application (Wood); and in children 
who cannot gargle, it may be applied with a hair pencil. So- 
lutions of zinc, or nitrate of silver, are also of service. Ul- 

27, 



354 SCARLET FEVER. 

cerations may be touched daily with a solution of nitrate of 
silver (one drachm to two ounces of water) / applied by means 
of a hair pencil or a sponge probang; while a weaker solu- 
tion (grains v. to x. to two ounces of water) is at the same 
time injected through the nostrils when there is discharge, 
and it gives great relief. Turpentine and glycerine in equal 
parts brushed over the ulcerated throat is also a valuable ap- 
plication, and the sulphurous acid spray may be of service. 
In. swelling of parotid and submaxillary glands, ice in bags 
of oil silk fastened round the neck and angle of the jaw, with 
lumps of ice in the mouth, diminish engorgement, and tend 
to avert suffocation. These details are giv*en because the 
physician must decide, upon the merits of the individual case, 
the nature of the treatment he will adopt. It must be re- 
membered that cases of scarlet fever, if left to themselves, 
with rest and careful nursing, will generally get well unless 
the epidemic constitution is a malignant type. The mere 
intensity of the fever is no ground for active interference by 
way of treatment, if the pulse is full and of good strength. 
Much is to be trusted to the shortness of the fever, remem- 
bering that there is no disease in which the patient is more 
apt to be delirious, and in which the temperature may reach 
a high degree, with less danger, than in scarlet fever, (W. T. 
Gairdner, Clinical Medicine.) On the other hand, it 
must also be remembered that any continuous and excessive 
increase of the temperature of the body may be followed by 
the occurrence of adynamia and threatened paralysis of the 
heart from excessive prostration, and that such cases sud- 
denly and urgently demand such therapeutic interference as 
may tend to reduce temperature and maintain the strength. 
Treatment by the cold water douche or affusion, as orig- 
inally advocated by Drs. Jackson and Currie, is now again 
recommended in the treatment of malignant scarlet fever, 
where the cerebral symptoms are early and severe. Nie- 
meyer and others bear testimony to its having a most markedly 
beneficial effect. The patient may be placed in an empty 
tub, and have the cold water poured over him, or his naked 
body may be wrapped in wet sheets, to be renewed and re- 
applied at intervals of ten to fifteen minutes, the patient be- 
ing put to bed in the interval. If either of these measures 
fail, then such powerful stimulants as carbonate of ammonia, 
camphor, or alcohol, may be had recourse to, administered 
by enemata if need be, combined with milk or beef-tea, or 
gruel. 



SCARLET FEVER. 355 

Preventive Treatment. — Mere fumigation will not, it should 
be remembered, destroy the miasmata in the sick-room; and, 
consequently, the doctrines of separation, of ventilation, and 
of cleanliness, are as imperative in this disease as in small- 
pox. The isolation of healthy persons from those affected 
with the disease, and from those who have intercourse with 
such patients, is essential, and is the only rule that promises 
any good results. The following rules (drawn up from the 
experience of Drs. Ballard and Budd) ought to be carried 
out in every house where conveniences can be obtained; such 
conveniences ought to exist in every hospital, and in the 
houses of the poor they ought to be carried out as far as 
practicable (i.) Remove from the sick apartment all su- 
perfluous woolen or textile matters, such as carpets, curtains, 
and anything of that nature, which are known to be reten- 
tive of disease germs. (2.) Measures of disinfection should 
be used as early and as thoroughly as possible. Carbolic 
acid in solution, or as carbolate of lime, is especially useful 
to sprinkle on the floor, and with which all parts of the room 
may be washed prior to cleansing and lime- whiting; and all 
articles to be washed ought to be soaked first in a solution 
of carbolic acid. (3.) A basin charged with chloride or car- 
bolate of lime, or some other convenient disinfectant, is to be 
kept constantly on the bed for the patient to spit into, which 
must be emptied and replaced at regular intervals. (4.) A 
large vessel (a tub) containing water impregnated with Con- 
dy's fluid, or carbolic acid solution, should always stand in 
the room (or near by) for the immediate reception of all bed 
and body linen on its removal from the person or contact 
of the patient. (5.) In place of using pocket-handkerchiefs, 
use small pieces of rag for wiping the mouth and nose, so 
that each piece, after being used, may be at once burned. 
(6.) Two basins, one containing Condy's fluid or carbolic 
acid solution, and another containing plain soft water with 
carbolic soap, and a good supply of towels, must always be 
ready and convenient, so that the hands of nurses may be at 
once washed, first with soap and water, and then in Condy's 
fluid water without soap after they may have been soiled by 
specific excreta. The dresses of nurses and attendants 
should be of linen, or smooth washable material. (7.) 
Glasses, cups, and other vessels used by or about the patient, 
arc to be scrupulously cleaned before being used by others. 
(8.) The discharges from the bowels and kidneys are to be re- 
ceived, on their very issue from the body, into vessels charged 



356 SCARLET FEVER 

with disinfectants. (9.) To prevent the minute particles of 
desquamation from flying off as impalpable powder, their 
power for evil must be destroyed in situ, by anointing the 
surface of the body (the scalp included) twice a day with 
olive oil. It may be slightly impregnated with camphor, 
which Dr. Budd considers sufficient, or carbolic acid. The 
process relieves the itching of the skin, and is very soothing 
to the patient. So soon as efflorescence is observed on the 
skin of the neck and arms (as early sometimes as the fourth 
day), which marks the first liberation of the germ-carriers of 
the specific disease-poison, the employment of the oil is to 
begin, and ought to be continued until the patient is well 
enough 'to take ,a warm bath, in which the whole person 
(scalp included) is well scrubbed, carbolic acid soap (Cal- 
vert's or Macdougall's) being abundantly used during the 
process. These baths are to be repeated every second day, 
until four have been taken, when, as far as the skin is con- 
cerned, the disinfection may be regarded as complete, al- 
though a further quarantine of a week may be advisable. 
(10.) The chamber in which the sick person has been con- 
fined must now be thoroughly washed out, using freely car- 
bolic acid and soft or black soap (which may now be got 
combined for the purpose) {Brit. Med. Journ., 1869, Jan. 9, 

P- 23). 

If a patient be from the outset thus isolated from all who 
are susceptible of contagion, — if everything proceeding from 
him is drenched with chemical disinfectants before it leaves 
the sick-room, — if the exhalations from the skin, and 
the peeling skin itself, are mechanically imprisoned by 
inunction with oil until they can be removed by a warm 
bath, — and if all clothing, bedding, and furniture are 
disinfected at the close of the illness, a case of scarlet 
fever ought to remain barren of results. But to carry 
out such a process thoroughly requires the command of 
space, of money, and of attendance; and requires also wis- 
dom and self-denial on the part of relatives and friends. If 
it were possible to begin to-morrow, and to carry it out in 
every case, scarlet fever would have ceased to exist in the 
country at the end of two months, and it is possible, or even 
probable, that it would never -return. " When, however, we 
look abroad at the actual condition of the people among 
whom the disease works its ravages, we see at once that, with 
regard to very many of them, and especially with regard to 
the poor in towns, isolation and disinfection are no more 






SCARLET FEVER. 357 

than idle words. In the class above the very poor, among 
small tradespeople, small employers, and the like, where the 
adoption of proper measures, although difficult, would not 
be impossible, it is rare to find the intelligence and the ac- 
tive conscientiousness that would induce them to bear re- 
straints, to take trouble, and to incur loss, for the sake of 
preventing injury to their neighbors. Even among the 
wealthy and educated, disinfection and isolation are but im- 
perfectly carried out. Such people like to do as they please, 
and resent dictation from medical men. If the cases are 
severe, mental anxiety and distress break down the barriers 
of precaution. If they are trivial, strict precaution would 
too often be thought fussy and unnecessary. Medical men 
cannot in such cases enforce what is right. They can only 
recommend it; and they recommend it subject to the remem- 
brance that their business is to heal the sick, not to quarrel 
with the healthy. It is a curious weakness of human nature, 
that many otherwise rational creatures are angry at the sug- 
gestion that their loved ones can be sources of danger to all 
around them, or that their house is properly shunned by 
the neighbors: and beyond this there is the belief, not alto- 
gether unfounded, that it is useless to isolate and disinfect 
in a single case, where there is no reason to believe that a 
similar course will be generally adopted. In the case of 
schools and public institutions, it might be well to prevent 
dispersion by positive enactment. But in other instances, if 
the principle were once asserted and acted upon, that an in- 
fectious disease must be registered, as a matter of public 
concern, public opinion would do the rest. Such provisions 
as we have suggested are, perhaps, as much as could be at 
present carried into effect; and their influence, both sanitary 
and educational, would be of incalculable value." 

There are also beginning to arise some sceptical misgiv- 
ings regarding our present hygienic views and practice with 
regard to scarlet fever. " One failure starts a doubt in a be- 
liever's mind; a second confirms it; a series of failures makes 
one look out for a better creed. Are we doing any good 
with our present preventive means ? If they could be uni- 
versally enforced, as they have been in isolated families with 
disciplined minds, they would succeed; but when this is at- 
tempted with large thickly packed communities, can they be, 
or have they ever been, successfully enforced ? By the imper- 
fect execution of them through the length arid breadth of the 
land, do we increase or lessen the mortality from disease ?" 



35^ SCARLET FEVER. 

These questions were put by Dr. Davies, of Bristol, who, 
writing of an epidemic of scarlet fever there in 1875, con_ 
tinues as follows- : — " I feel certain that we increase the anx- 
iety of the domestic and social troubles of the public by 
our preventive measures; and I feel doubtful of the answer 
to the former question. Take, for example, an imaginary 
but typical case in private practice. There is a family 
named X., in easy circumstances. They have five children 
— three boys and two girls. There is an epidemic, of a very 
mild type, of scarlet fever in the locality. Hundreds have 
had the disease; but there has been no death. The season 
is July; the weather rainy, the atmosphere moist. The 
youngest boy, aged 4, contracts the disease in the prevalent 
mild type. The other four children, by the advice of their 
medical attendant, are sent to a distance, and escape the in- 
fection. The sick child recovers. Two years elapse. The 
eldest son goes to Eton, Rugby, Marlborough, or some other 
public school. An epidemic of a severe type has just broken 
out where he is ; he contracts the disease. The parents are 
telegraphed for to see their son, supposed to be dying. 
They travel to and fro three hundred miles. The patient 
ultimately recovers, and escapes only by the skin of his teeth. 
The school is temporarily broken up. The convalescent is 
sent to a fashionable watering-place before he is properly 
disinfected, and there he spreads the disease. The second 
son has escaped, through being kept at a distance from his 
brother. He has, in the course of time, taken his degree at 
college; has been admitted as a barrister; has, after a long 
struggle, made his position; has been married. He passes 
through Paris on his honeymoon. The weather is cold, the 
wind easterly. In Paris an epidemic of scarlet fever pre- 
vails. He contracts the disease and dies in a strange land; 
and leaves his young bride a widow among strangers. In 
time, the eldest girl is married to a rich man. She is in due 
time confined of her first-born. The bells are ringing, and 
all goes on merrily as a ' marriage bell.' A fortnight after- 
wards, that house is desolate. In that house are now only 
a bereaved husband and motherless infant; the subtle seeds 
of this mysterious disease have been inadvertently introduced 
to the puerperal patient in the nurse's shawl, or on the sleeve 
of the doctor's coat. I will not follow this case further; but 
ask, in all seriousness, would not life and suffering have been 
saved if all the family had been allowed to pass through the 
disease when it first appeared among them in a mild type, 



SCARLATINA SCURVY. 359 

when they were all children ? I wish it to be thoroughly un- 
derstood that, as a health-officer, I have never had the moral 
courage to discard my former profession of faith, and to un- 
dertake the responsibility of giving practical effect to my 
doubts. I have never used disinfectants so extensively as 
during the present epidemic, and yet our failure is complete. 
The doubts I have expressed do not in any way extend to 
typhus and enteric fevers, small-pox, and Asiatic cholera. It 
is a fact beyond contradiction that occasionally this tiger of 
pathology seems to stalk abroad, having left both claws and 
teeth at home. Could we not play with him then ? Inocu- 
lation from mild cases of variola previous to the discovery of 
vaccination proved of immense benefit. We can import 
scarlet fever. We can choose our type and season of the 
year. Is there a milder exanthem of an allied species that 
can prevent or modify this disease ? Rotheln is nearly 
allied, is very infectious, but harmless. Does it modify 
scarlet fever, or is it modified by it ? I have for some time 
looked upon it with affection, but am afraid to theorize on 
the subject. Can any one throw light on this unexplored 
field ? Observation convinces me that there is some un- 
known condition which gives immunity to some persons from 
scarlet fever: what is this condition ? An analogous condi- 
tion was known in the Vale of Berkeley regarding small-pox 
before the days of Jenner, and might have remained un- 
known to the outer world had not that great man unearthed 
it. Who will be the Jenner of scarlet fever ?" A somewhat 
similar argument is used by Thomas in his article on scar- 
latina in Ziemssen's "Cyclopaedia," Vol. II., p. 300. 

Different prophylactic medicines have been recommended; 
amongst which belladonna has had the greatest number of 
advocates, but its value has diminished greatly, as the 
weight of testimony is against its possessing any prophylactic 
virtues (Wood). Even when continued for a week, it affords 
no protection against scarlet fever (Niemeyer). 

Scarlatina — See Scarlet Fever. 

Scorbutus— See Scurvy. 

Scurvy. — Definition. — A morbid state characterized by 
sponginess of the gums and the occurrence of livid patches 
under the skin, of considerable extent, which are usually 
harder to the touch than the surrounding tissue. An altered 
state of the albumen of the blood is associated with this con- 
dition, and the phenomena are brought about by a deficient 



360 SCURVY. 

supply of the organic vegetable acids, or of the salts of fresh 
vegetables. It is ushered in by debility, lassitude, lowness 
of spirits, attended by fetor of the breath, and the gums 
swell by irritation, till they overhang the teeth in palmated 
excrescences. The livid subcutaneous patches and spots 
appear upon the skin of considerable extent, especially on 
the lower extremities and among the roots of the hair. Spon- 
taneous haemorrhages may take place from the mucous ca- 
nals; contractions of the muscles and tendons of the limbs 
occur, with pains, and sometimes superficial ulcerations. 

Treatment. — The disease, " so fatal when left to itself, is 
cured with the greatest facility. Symptoms apparently the 
most grave and serious vanish as if by magic, and without 
leaving behind them any serious injury to the constitution. 
The sanious discharge from scorbutic sores has been known 
to change color, and to become healthy in a few hours 
after the commencement of treatment. In pure cases of 
scurvy the blood, and the blood only, is at fault," (Parkes) 
"Lemon juice," writes Dr. Watson, "is really a specific 
against scurvy, whether it be employed as a preventive or as 
a remedy. It supplies something to the blood which is essen- 
tial to its healthy properties." The potato seems to be no 
less efficacious as a remedy and preventive (Budd), and all 
the antiscorbutic remedies are most efficient in the form of 
juice — from raw and uncooked fruit. The reader will find 
a most interesting account of the efficacy of potatoes and of 
onions in Dana's Two Years before the Mast — a book well 
worth reading. The antiscorbutic principle, whatever it may 
be, is in greatest amount in unripe fruits; it lessens gradu- 
ally as they ripen; and if the juice be obtained, the princi- 
ple disappears, or is decomposed and rendered inefficient, 
when fermentation occurs. When lime-juice becomes musty, 
a mucilaginous principle is developed at the expense of the 
citric and malic acids; and the percentage of citric acid 
gradually decreases (Sir William Burnett, Parkes). Good 
lemon juice seems to be more effectual, however, than pure 
citric acid; probably from its containing malic and tartaric 
acids besides citric, and from the citric acid being in the 
form most easily absorbed and decomposed by the digestive 
organs of man. The Materia Medica gives numerous anal- 
ogous examples of the superior efficacy of a medicine in its 
natural combinations (Parkes). This is all we can yet say, 
however, regarding the actions of either of these means of cure, 
notwithstanding the researches of the chemists of the pres- 



SCURVY. 361 

ent day. Moreover, it is sufficient; and with such remedies at 
command, the prevalency of scurvy in merchant vessels, or in 
any navy, ought not to exist. " The one thing wanted in order 
that scurvy should be entirely banished from the mercantile 
marine is proper provision for the dietary of the crew, — such 
provision as is enforced in emigrant ships, where each per- 
son's weekly allowance must have in it at least 8 oz. of pre- 
served potatoes, and 3 oz. of other preserve 1 vegetables (car- 
rots, onions, turnips, celery, and mint), besides pickles and 3 
oz. of lime-juice; where, also, there is considerable variety 
of bread stuff ; and where, on two days in the week, pre- 
served (not salted) meats must be given. With such a diet- 
ary as this, the details of which might be varied, provided 
its principle were adhered to, the occurrence of scurvy would 
.be impossible. And even with dietaries inferior to that just 
described, scurvy would not occur as it does, if but the pro- 
visions of the ' Merchant Shipping Act' (17 and 18 Vic, c. 
104) were obeyed, — that whenever a crew shall have been 
consuming salt provisions for ten days, lime juice or lemon 
juice and sugar shall be served out at the rate of half an 
ounce each per day; and if, during the voyage, the opportu- 
nities which offer themselves were fairly used for getting new 
supplies of fresh animal and vegetable food; but owners dis- 
obey the law, and captains neglect opportunities to counter- 
act the results of this disobedience. Owners, notwithstand- 
ing the law, will send forth their ships on long voyages with- 
out any provision of lime-juice, or with lime-juice insufficient 
in quantity, or with lime-juice of which the quality is bad; 
and captains, with half their crews more or less disabled, are 
known to run past St. Helena or the Western Isles, when a 
few hours' delay would obtain sufficient provisions to repair 
the mischief occasioned by first neglect" (Simon and 
Barnes's Sixth Report on Public Health, 1864, p. 20). It is 
perhaps hardly fair to attribute the improved health of the 
navy entirely to the introduction of a daily allowance of 
lemon juice, considering that the quantity of the diet was 
greatly increased, and its quality greatly improved, contem- 
poraneously with this addition. It is gratifying, however, to 
see how largely these combined measures have improved the 
health of the navy, and rewarded the cares of those who su- 
perintend it. During the nine years preceding these changes 
the sick seamen sent to the hospitals were t in 3.9, while in 
the nine succeeding years the proportion was only 1 in 8.4; 
so that not only has scurvy almost disappeared from ships 



362 SCURVY. 

of war and naval hospitals, but the efficiency of the navy has 
actually been increased threefold. 

Dr. Parkes advises that the following measures be adopted 
in time of war, or in prolouged sojourn on board ship, or at 
stations where fresh vegetables are scarce: " (1.) The supply 
of fresh vegetables by all means in our power. Even unripe 
fruits are better than none, and we must risk a little diar- 
rhoea for the sake of their antiscorbutic properties. In time 
of war every vegetable should be used which it is safe to use, 
and when made into soups all are tolerably pleasant to eat. 
(2.) The supply of dried vegetables, especially potatoes, cab- 
bages, and cauliflowers; turnips, parsnips, &c, are perhaps 
less useful; dried peas and beans are useless. As a matter 
of precaution these dried vegetables should be issued early 
in the campaign, but should never supersede the fresh vege- 
tables. (3.) Good lemon juice should be issued daily (1 oz.) 
and it should be seen that the men take it. (4.) Vine- 
gar (-g- oz. to 1 oz. daily) should be issued with the rations, 
and used in the cooking. (5.) Citrates, tartrates, lactates, 
and malates of potash, should be issued in bulk, and used as 
drinks, or added to the food. The easiest mode of issuing 
these salts would be to have packets containing enough for 
one mess of twelve men, and to instruct the men how im- 
portant it is to place them in the soups or stews. Possibly 
they might be mixed with the salt, and issued merely as salt" 
("Prac. Hygiene," 2nd Ed., 1866, p. 466). 

Our recent Arctic expedition, in 1876, is of interest for 
two reasons: (1.) As regards a peculiar theory as to the ac- 
tion of lime-juice which the commander of that expedition 
entertained and acted upon, based as it was upon a ground- 
less and absurd hypothesis, that by doubling the dose of 
lime-juice for a month he believed he could, so to speak, 
"saturate " his men with it before they started on an im- 
portant sledging expedition, so that they might be able to do 
without it on these journeys. Lime-juice is simply an article 
of diet; and is no more " cumulative " in its action than any 
other aliment which goes to nourish the body. Its nutritive 
influence continues for so long and no longer than the time 
when it is continued and assimilated as an article of diet. 
The assumption of the theory was entirely gratuitous and 
unfounded; and to have acted upon it against competent 
medical opinion was unjustifiable. (2.) Another theory was 
entertained to palliate the omission of lime-juice from the 
sledging rations, namely: — that lime-juice when exposed to 



SCURVY. 363 

an extreme degree of cold deteriorates and ceases to have 
any antiscorbutic properties. 

" This theory was not only disproved by the evidence of 
the medical officers on other sledging expeditions, but was 
effectually answered by the fact that the whole expedition 
was virtually saved from the most fearful mortality from 
scurvy by the opportune discovery of a depot of lime-juice 
left five years before by the " Polaris " expedition, lying in 
a cask on the ice exposed to the extremity of cold alterna- 
ting with heat. It had also been much weather-beaten, and 
on its surface mixed with snow; but it nevertheless proved 
to be in no respect deteriorated in its antiscorbutic powers, 
and served to keep off the last extremities of disease from 
the sledging parties to whose relief it was sent in time. It 
appears, indeed, to us, and it will appear, we think, to any 
one who reads the whole narrative, that, but for the timely 
discovery of this depot of the "Polaris" lime-juice, and its 
utilization for the sledging parties, there is good reason to 
fear that so large a proportion of the crews would have been 
destroyed by scurvy, that it is doubtful whether the whole 
expedition would not have been lost from the want of suffi- 
cient power to bring the ships out of the ice. However this 
may be, the frozen lime-juice rendered the most essential 
services, and the theory that freezing destroys its virtues is 
most effectually disposed of " {Brit. Med. Journal, March 
10, 1877). 

In fact there is nothing in the history of our latest Arctic 
expedition of 1876, which does not point to the cause of the 
outbreak of scurvy as similar to all those which history has 
already recorded; and which will again produce the disease 
if the teachings of history are similarly neglected and set 
aside. 

The great body of evidence taken by the committee ap- 
pointed to inquire into the causes of the outbreak of scurvy 
in the Arctic expedition fully shows that " the outbreak was 
due essentially to the omission — or, rather, to the refusal — 
of Captain Nares to send lime-juice with the sledge parties. 
It was shown that the provisions of the ships were ample in 
quantity and excellent in quality; and, further, the commit- 
tee having had before them the preliminary memorandum 
by Sir Alexander Armstrong, the Director-General of the 
Medical Department of the Navy, strongly and explicitly re- 
quiring the issue of a daily ration of lime-juice, and having 
heard Sir George Nares' explanation of the reasons which 



364 scrivener's palsy. 

induced him to act in defiance of that memorandum, decided 
that in doing so he made himself responsible for the out- 
break of scurvy which occurred, and that he had no suffi- 
cient reason for not carrying out the rules laid down in the 
memorandum." 

" It is a satisfaction to find that throughout the whole of 
this inquiry the Medical Department of the Navy comes out 
with the utmost possible credit. Nothing could be more 
clear, more explicit, more absolutely prophetic than the 
memorandum which was furnished to Sir George Nares by 
the Admiralty from Sir Alexander Armstrong, on the im- 
measurable importance of supplying the men with a daily 
ration of lime-juice. The whole of his direction for the 
maintenance of the health of the men are indeed most able, 
practical, and judicious: and, had they been strictly followed 
out, the results would have been very different. The con- 
duct of all the medical officers of the expedition appears to 
have been such as to merit and to receive the warmest ap- 
probation of their superiors from first to last, and they show- 
ed a devotion to duty which is entirely comparable with that 
displayed by the officers and men of this gallant expedition 
generally. They can seek for no higher praise, and it is on 
all hands conceded that they merit no less. One moral of 
this inquiry, which is salient on the face of it, and which we 
can hardly be expected to abstain from pointing, is, that 
combatant officers will do well always to respect the func- 
tions of the medical officers, and to attribute just weight to 
medical recommendations. In framing false medical theo- 
ries, ar.d in assuming the responsibility of refusing to act 
upon his medical instructions, Sir George Nares brought a 
great disaster upon this expedition; and he assumed the full 
responsibility of it " {Brit. Med. Journal, March 10, 1877.) 

Scrivener's Palsy. — Definition. — Morbid excitement of 
the motor fibres of the nerves of the muscles of the fingers 
and thumb holding the pen, resulting in cramps, so as com- 
pletely to prevent writing, and thus the condition becomes 
equivalent to a local palsy or paralysis. 

Treatment. — Complete rest from the usual mechanical use 
of the hand must be insisted on. Nourishing food, with a 
milk diet in abundance, or cod-liver-oil, are essential. In 
one case division of the muscle in which the cramp seemed 
first to commence had a good effect (Stromeyer). In four- 
teen days after subcutaneous section of the long flexor of the 
thumb, the patient was again able to write. Dieffenbach 



SCROFULA. 36$ 

often repeated a similar operation, but without success. 
These may be regarded as very radical surgical methods of 
securing absolute rest to the wearied muscles. Mr. Solly, in 
his lately published surgical experiences, described several 
cases of this peculiar affection, in which tonic treatment, 
with rest from writing, was attended with good results. 
Niemeyer has been successful with the galvanic current. 
He applied the current to the muscles of the thumb and 
index finger. Exercise of the affected muscles materially 
tends to increase the disease. 

As to medicines, when the disease has not gone beyond 
the sensation of heat and cramps in the ball of the thumb, I 
have seen good results from the syrup of the phosphates of 
iron, quinine, and strychnia; and generally those remedies 
noticed under the subject of anaemia may be prescribed. 
Mechanical appliances, such as contrivances which fill up, 
as by a ball, the palm of the hand on which the fingers rest 
in writing, have been of service; and there are also appli- 
ances by which writing may be accomplished without the aid 
of the fingers, and which therefore may be of service in 
securing rest to them. 

Scrofula. — Definition. — A constitutional disease, result- 
ing in the deposit of a soft unorganized matter of a white or 
pale-yellow color, firm, resembling curd or soft new cheese, 
but less tough, sometimes granular and friable, and consist- 
ing of a large proportion of albuminous matter. It is often 
found mixed with purulent-like fluid, or occurring in round- 
ed masses of different degrees of firmness, and varying in 
bulk from that of a millet-seed to a hen's egg or larger ; 
sometimes contained within natural canals and cavities of 
the body, and sometimes* inclosed in cysts, or occasionally 
diffused as if by infiltration through the texture of a part. 
To the rounded masses the name of tubercle has been given; 
and the substance itself has been named scrofulous or tuber- 
culous matter. Scrofula also expresses itself in specific 
forms of inflammation or. ulceration. It manifests a remark- 
able tendency to certain specific forms of nutritive disorder, 
which are strikingly wasting in their effects upon the body, 
namely: — (a.) Scrofula with tubercle; (b.) scrofula without 
tubercle; and (c.) certain local scrofulous affections, such 
as eruptions of a peculiar kind, many cutaneous ulcers, cer- 
tain enlargements of the joints, tubercular meningitis, hydro- 
cephalus, scrofulous ophthalmia, tubercular pericarditis, 
scrofulous diseases of glands, phthisis pulmonalis or pul- 



$6<J SCROFULA. 

monary consumption, acute miliary tuberculosis, tabes 
mesenterica, and tubercular peritonitis. 

Treatment. — (a.) Preventive — There is perhaps no subject 
in the whole range of medical science which the student 
ought to study more carefully than the cachexia, or special 
form of ill health associated with the occurrence of tubercle 
and scrofulous affections as here described. As a practi- 
tioner he will find that he becomes often painfully concerned 
in the deepest interests of families and society, through the 
threatened or actual ravages of scrofulous diseases. The 
extensive prevalence of the scrofulous cachexia — the great 
and almost inevitable mortality of the scrofulous diseases 
themselves when completely developed, stamp the morbid 
state associated with them as a topic which, at the outset of 
the student's career, ought to engage a large share of his 
study. Most assuredly the physician will have to turn his 
knowledge of the pathology of scrofula to account in every 
phase of his professional life. When he fully appreciates 
what experience has adequately demonstrated, that the 
scrofulous cachexia springs from causes over which the pub- 
lic (rather than the medical profession) have control, he 
must be at once impressed with the belief and encouraged 
with the hope, that when he acquires the confidence of fam- 
ilies in the practice of his profession he may exercise a pow- 
erful influence for good in teaching how much the public 
may control the; ravages of scrofula and consumption by 
prudent marriages,' by sanitary attention to offspring, and 
by the necessity of free ventilation and of fresh air in dwell- 
ings. There are several circumstances which show the great 
influence of public sanitary measures in controlling the 
development of scrofula, when these measures are scientific- 
ally directed to the preservation of general health, especially 
where men are associated together in great communities — an 
influence much greater than the best directed efforts of the 
medical profession can establish through their materia med- 
ica. It is by the mode of life as citizens of the world, in 
the social relations of husbands and wives, parents and child- 
ren; in the public relation of masters and workmen, that the 
extent and ravages of consumption and scrofula are to be 
controlled. It is by a strict attention to the rearing of off- 
spring, and in the subsequent regulation of food, clothing, 
cleanliness, and occupation; in the choice of a profession, 
and by many other circumstances which have an obvious 
influence (perhaps at first sight inappreciable) on the main- 



SCROFULA. 367 

tenance of the general health, that our hopes of success as 
practitioners of medicine must rest in the prevention of that 
bad habit of body which develops and propagates the scrofu- 
lous diseases in civilized society. 

(b.) General Treatment. — The general treatment now in 
most repute is founded on the doctrines — (1.) That 
scrofulous local lesions will heal of themselves if the 
nutrition of the system can be maintained and the con- 
tinuous growth of tubercle arrested ; (2.) that the periods 
of frequent temporary arrest of all the general and local 
symptoms of disease ought to be diligently taken ad- 
vantage of to improve and preserve health by hygienic 
means (3.) that the efforts of the practitioner should be 
directed to the digestive rather than to the pulmonary sys- 
tem; (4.) that the kind of morbid nutrition in the body 
generally, and altered morphological change in the tissues 
of the organ where the deposit takes place, appear to be 
chiefly due to excess of albuminous and deficiency of fatty 
elements in the chyle. The treatment, therefore, to be pur- 
sued must be essentially reparative of the waste of tissue 
generally; corrective of what has been unfit in the indivi- 
dual diet and mode of life; and, lastly, supplementary of 
the elements of nutrition which have been deficient. During 
the past thirty years in Germany, and twenty-three years in 
this country, the treatment of scrofulous affections has gradu- 
ally but steadily become more and more firmly based on those 
pathological doctrines which the late Dr. J. H. Bennett, of 
Edinburgh, was mainly instrumental in first elucidating, and 
in earnestly recommending to the notice of the profession 
generally in this country. The view here taken regarding 
the nature of scrofula leads to the belief that — (1.) The 
biood is impoverished through the preliminary dyspepsia 
which precedes the growth of crude tubercle; (2.) that in 
pulmonary phthisis the growth of crude tubercle results in a 
consolidation primarily in the air vesicles; (3.) that the 
successive formation and softening of these crude tubercles 
lead to ulcerations of the pulmonary and other tissues — to 
the infective processes which set up the growth of true 
miliary tubercle — and, promotes wasting of the body gener- 
ally. 

It nas been now fully shown, especially by the observa- 
tions of Dr. Bennett, in the first instance, confirmed by the 
extensive experience of the physicians at the Brompton Hos- 
pital for Consumption, in London, that such treatment as is 



368 SCROFULA. 

directed to remove the malassimilation of food frequently 
checks the tendency to the repeated occurrence of tubercles, 
while those which previously existed remain harmless ; that 
general symptoms and physical signs may disappear com- 
pletely ; and that even extensive excavations in the pulmon- 
ary tissue may heal up and cicatrize. According to the tes- 
timony of Dr. Wood, of Pennsylvania, the fatal results have 
not only been postponed, but the death-rate from phthisis 
has diminished in the principal cities of the United States 
since such principles of treatment have been adopted. The 
indications of general treatment are therefore: — (i.) To im- 
prove the faulty nutrition, which is the cause of the scrofu- 
lous cachexia, and of the exudations assuming the characters 
of tubercle ; (2.) To subdue the fever which attends the 
growth and changes going on in the tubercle-nodules, and to 
favor the absorption either of the entire exudation, or of 
such portions of it, that what remains may undergo such 
changes as are consistent with its future harmless existence 
in the organs or other parts where it may have grown : (3.) 
To prevent the recurrence of fresh exudation by careful at- 
tention to hygienic regulations, especially during the inter- 
vals of apparent return to health. 

To fulfil the first of these indications it is of all things 
important that fatty matter be assimilated in large quanti- 
ties, and it appears that such is most readily absorbed and 
assimilated when in the fluid condition. The substance of 
all others found most beneficial has been cod-liver oil. At 
the Brompton Hospital more than 600 gallons of this oil are 
used annually. There, on a great scale, its merits have been 
tested and compared with the effect of treatment conducted 
on general principles, and irrespective of its use. The result 
has been to confirm, in the estimation of the medical profes- 
sion, the great value of the remedy in the treatment of 
phthisis, when appropriately administered, and combined 
with the use of such other measures as any special circum- 
stances in the individual patient may require (Thomson). 
The general opinion of the profession with regard to cod- 
liver oil may be summed up in the statement originally made 
by Dr. Bennett, — namely, that " it rapidly restores the ex- 
hausted powers of the patient, improves the nutritive func- 
tions generally, and stops or diminishes the emaciation. The 
night perspirations subside, the cough is quieted, and the ex- 
pectoration is diminished after the oil has been used for a 
few weeks. A very constant and well-marked favorable 



SCROFULA. 369 

change under its use is to be noticed in the diminution of 
the pulse, which gradually but steadily has been observed to 
come down at the rate of five or six beats weekly ; and dur- 
ing the same period the weight of the body has been known 
steadily to increase at the rate of half a pound to a pound. 
In females it is a significant and highly favorable symptom 
when the catamenia return after the oil has been used for 
some time. The usual dose adopted by the late Dr. Thomp- 
son, at the Brompton Hospital, is one or two teaspoonfuls 
twice a day at first; and gradually increasing the quantity to 
half an ounce three times a day. Dr. Bennett recommends 
somewhat larger doses — namely, for an adult, a tablespoon- 
ful three times a day. which may often be increased to four 
or even six with advantage. When the stomach is irritable, 
however, a tea or a dessert-spoonful is enough to commence 
with. It appears from the observations of Dr. Thompson 
that no additional advantage is obtained by pushing the oil 
beyond the limits of the doses adopted by him at the Bromp- 
ton Hospital, from the fact that where its use has most obvi- 
ously increased the weight of the body> to the extent in one 
instance of a pound per week for twenty-one weeks, only 
three pints had been taken during that time. The kind of 
oil used, as far as coarseness or fineness is concerned, seems 
not to affect the beneficial result in any material degree. 
Some patients even prefer the coarse to the fine oil. The 
experience of some is, moreover, favorable to combining the 
oil with liquor potassae as an emulsion ; and as it appears 
that undue acidity prevails as well in the stomach as in the 
intestinal canal, the addition of the alkali ought, on theoreti- 
cal grounds, to be advantageous. It seems also that, when 
cod-liver oil was first used as a medicine, more than fifty 
years ago, in the treatment of rheumatism, it was then ordi- 
narily combined with an alkali. It may be taken, however, 
unmixed, or it may be floated on milk, or nitro-muriatic acid 
mixtures, or on lemonade, soda-water, lemon juice, or on a 
saline draught during effervescence, when such combinations 
are suited to the patient. Creosote has been recommended 
to be added, as it is said to render the stomach more tolerant 
of the remedy. The following formula, quoted from Dr. 
Thompson's "Clinical Lectures on Pulmonary Consumption," 
yields a palatable mixture, which ought to be combined as 
an emulsion: — 

"An ounce and a half of cod-liver oil, four drops of creo- 
sote, two drachms of compound tragacanth powder, and four 
24 



37o 



SCROFULA. 



ounces and a half of aniseed water. Of this mixture an 
ounce may be taken thrice daily." 

Besides cod-liver oil, other animal fats and oils, where they 
can be taken and assimilated, are sure to be followed with 
benefit. Hence -milk rich in fatty matter, such as asses' 
milk, and milk drawn from the cows at a short interval after 
the greater part of their milk has been withdrawn, and which 
is known in Scotland as " afterings," are found to be fol- 
lowed by improvement Avhere they are persevered in and are 
assimilated. So also has it been with cream and butter. Dr. 
Bennett instances the partial success occasionally of caviare, 
bacon, pork, mutton chops, and the marrow of the bones of 
oxen ; while Dr. Thompson instances the good effects he has 
obtained from the use of oil obtained from the foot of the 
young heifer (neat's-foot oil). The administration of any of 
these remedies is quite consistent with doctrines now taught 
regarding the pathology of scrofula, and it is useful to know 
- their individual value, in order that in particular cases one may 
fall back upon their use where a change may be desirable. 

It has been considered that some of the good effects of 
cod-liver oil may be due to the biliary elements with which it 
has been incorporated. This view is not supported by the 
experiment of adding ox-gall to other animal oils not derived 
from livers, as no beneficial results have been observed to 
follow. But as the active principle of the gastric juice has 
been now successfully isolated by chemistry, and has been 
successfully used to aid the digestion of food in the stomach, 
might not some principle be obtained from the liver which 
might aid the assimilation of fatty substances when mixed 
with the intestinal juices ? 

In fulfilment of the second indication mentioned the 
propriety of abstracting blood has been much discussed. 
It has been already seen that febrile symptoms of a very 
severe kind sometimes attend the exudation and consolida- 
tion of crude tubercle. It is also a more or less frequent 
clinical observation that pneumonia, bronchitis, and pleuritis, 
in acute or chronic forms, are intercurrent attendants on the 
deposit and future changes of tubercles in the lungs. 
" Hence," as Dr. Bennett justly observes, " there are all 
kinds of intermediate changes between the simple and tuber- 
cular exudations constantly going on in the progress of a 
case of pulmonary tuberculosis. The phenomena of phthisis, 
pneumonia, pleurisy, and bronchitis, in their acute or chronic 
forms, may appear together, and be inextricably mingled, or 



SCROFULA 371 

they may succeed each other at intervals." Thus, scrofulo- 
sis, both as a constitutional and as a local disease, is scarcely 
ever free from exacerbations, the various local and con- 
stitutional states acting and re-acting on each other. While, 
therefore, on the one hand, the system requires an increas- 
ed and well-directed supply of nutritive materials, on the 
other hand, there are constitutional states of excitement, de- 
pending on local irritation, which require to be subdued, and 
which may even demand antiphlogistic treatment. What- 
ever theoretical view may be taken as to how the exudation 
may most readily be absorbed, all physicians are now at one 
as to the propriety of preserving the general strength, of effect- 
ing elimination of effete material, and of meeting antiphlogis- 
tic indications rather by diaphoretics, diuretics, emetics, and 
purgatives, than by abstracting any considerable amount of 
blood, either at once or at repeated intervals. In fact it is 
now observed that the administration of appropriate diet, 
and abstinence from lowering remedies, with cod-liver oil, 
while they correct the general nutrition, may be so regulated 
as to subdue the constitutional irritation by a perseverance 
in their use for a period of not less than four or six weeks. 
In fulfilling the third indication,the real power of the science 
of medicine may be demonstrated. It is by well-directed 
hygienic measures, successfully and efficiently carried out, 
that the real strength of the physician may be put forth to 
prevent the recurrence of fresh exudation; and his hygienic 
exertions towards the patient are to be redoubled during the 
temporary intervals of apparent return to health. It is now 
almost an axiomatic truth, that of all things which deterio- 
rate the constitution on the one hand, and influence pulmon- 
ary congestion on the other, none are so detrimental as im- 
pure and deficient air, together with frequent variations of 
temperature, a*id changes from sudden heat to chilling cold. 
These latter vicissitudes may be considered characteristic of 
the physical climate of Great Britain and Ireland. " The 
conditions of preventive treatment which have seemed most 
useful are nutritious food and proportionate great exercise 
in the free and open air. So important has this last con- 
dition proved to be, that it would appear that even consider- 
able exposure to the weather is better than keeping phthisi- 
cal patients in close rooms, provided there be no bronchitis 
or tendency to pneumonia or pleurisy " (Parkes, p. 445). 
Tonic treatment consists essentially in the adoption of those 
means which promote or stimulate the healthy nutrition of 



37'2 bUKOFULAo 

the body. Its elements exist in fresh air, abundant exercise, 
sufficient repose, and judicious diet. A hygienic code appli- 
cable to the tuberculous cachexia has been recently laid 
down by Dr. B. W. Richardson, in the second volume of the 
Sanitary Review, and very recently in a special work On the 
Hygienic Treatment of Pulmonary Consumption. It is de- 
rived from these elements of tonic treatment; and -as it puts 
well-known truths, too little appreciated, in a formal and more 
important aspect than is wont, its precepts are here quoted. 

I. A sitpply of pure and fresh air for respiration i?i constant- 
ly required by the tuberculous patient. — As it is known that if 
one per cent, of carbonic acid exist in a room, the air is un- 
fit for a healthy person, it is therefore much more so for a 
consumptive one. The temperature of a room ought to be 
equally maintained at from55° to 56 Fahr., ventilation and 
heating being effected by open fireplaces. A single room 
ought not to perform the two offices of a bed-room and a 
sitting-room. The sleeping-room ought not to afford less 
than 1,000 feet of space; and if larger, so much the more 
healthful will it be. In connection with these statements, 
while it is objected,' for obvious reasons, with much justice, to 
the treatment of tuberculous patients in special hospitals,there 
is much on the other hand that might be improved in all our 
hospitals, with reference to the arrangement of the patients, 
to secure to them fresher air than they generally obtain. 
" Constant though imperceptible movement of the air is the 
point to be attended to " — i. <?., thorough ventilation. All 
who are able to be out of bed ought to have their meals in a 
common room, which is not used for any other purpose, and 
is apart from the wards or dormitories. 

II. Active excercise in the open air is imperatively demanded 
by the tuberculous patient. — In the words of Dr. Jack- 
son, " He must be made to feel that the risk*is in staying in 
the house, and not in going out of it." But the skin must 
be perfectly protected; and while a chill, or inclement wea- 
ther, is to be avoided, the patient must go out in all seasons, 
without being too fastidious about the weather, walking ex- 
ercise being persvered in as much as possible. " The best 
climates for phthisis are perhaps not necessarily the 
equable ones, but those which permit the greatest number of 
hours to be passed out of the house" (Parkes). Next to 
diet, exercise in the open air is, of all things, the most im- 
portant: it should be carried as far as the vigor of the pa- 
tient will permit. It should not be done rashly, but boldly; 



scrofula. 373 

and, if possible, the patient ought to have faith in it; for 
without this he is not likely to pursue it so far as he can, 
and then he will not derive from it all the benefit which it 
can afford (Jackson). It is very important to remember, in 
regard to training animals and young persons, that they have 
much more extent and range of lung than are required in 
the quiet everyday pursuits of life. Less lung is used when 
the young person or other animal lies down or sleeps, or is 
depressed; and, on the contrary, walking, running, wrestling, 
the force of the passions, each or all of them bring the 
greatest amount of lung into action or use. In short, the 
amount of lung in use is an ever-varying quantity; and just 
as much lung may come to be used as a habit as the listless- 
ness or vigor of the individual moment requires. There is 
every range, every variety, till the top of the wind, the top 
of the speed (the full vital capacity) is attained (Sibson) 
Practically, therefore, the more fully the lungs are judiciously 
used, the more is their capacity nursed; and, conversely, 
the less they are used and expanded, the more useless they 
are likely to become, if not absolutely diseased. Under a 
judicious system of training, an undeveloped man, even al- 
though he may be feeble, narrow-chested, and sickly, may 
yet become active, full-chested, and healthy. We have 
numerous examples of this among the boys in our training 
ships for seamen. The over-fed, short-winded pugilist, 
rower, or cricketer, may in a few weeks be changed, by 
training alone, to the firm-fleshed, clear-skinned, long-winded 
winner of the boxing fight, the foot race, or the rowing 
match. It is this want of use that probably renders the 
apices of the lungs more liable to the growth of tubercle in 
them than in any other part of their substance. It is a por- 
tion of the lungs which has less play or expansion than any 
other portion, and is apt to be bound down by the sur- 
rounding parts. The apices are, therefore, the parts most 
likely to remain in a quiescent state of non-expansion, 
especially when acts of respiration are inadequately, per- 
formed, either owing to the constrained position of the body 
in certain trades, or from habitual stooping of the body from 
listles^ness of habit or want of vigor in the system. This 
quiescent state of the air-cells is favorable to the growth of 
tubercle; and thus the apices of the lungs are the most com- 
mon seat of tuberculous growths (Reviewer in Medical Mirror, 
Vol. I., p. 638). The effects of want of exercise and of im- 
pure air are thus most potent agencies in causing phthisis. 



374 SCROFULA. 

" The much greater prevalence of phthisis in most of the 
European armies (French, Prussian, Russian, Belgian, and 
English) can scarcely be accounted for in any other way than 
by supposing the vitiated atmosphere of the barrack-room to 
be in fault." In all the places where phthisis has 
prevailed, in the most varied stations of the army, 
in the most beautiful climates, the only common condition 
was the vitiated atmosphere which our barrack system every- 
where produced; "and, as if to clench the argument, there 
has been of late years a most decided decline in phthisical 
cases in these stations, while the only circumstance which 
has notably changed in the time has been the condition of 
the air" (Parkes, p. 91). Indeed, the air is rendered so 
so impure by respiration, that while an atmosphere so vitiated 
has a most injurious effect upon the health, contamination 
of the air has been so great, where lung diseases abound, as 
to give rise to the idea that phthisis appeared to be propagated 
by contagion (Bryson, Parkes). It is therefore within the 
power of the authorities of the Army and Navy so to direct 
the physical training of young persons, that the apparently 
sickly and the short-winded may in time be developed into 
the wiry and active young man, long in wind, sound in body, 
and lithe of limb — a result which, however, can only be at- 
tained by judicious feeding, careful exercise throughout the 
development of the body, and by the gradual nursing of the 
breathing powers. The opposite of this is seen in the break- 
ing down of recruits at a very early period of service in the 
army — within the third year — a result likely to be greatly 
obviated by the gymnasia introduced by Government for the 
physical training of recruits before and after they are in- 
structed in drill, by better and more abundant food, and im- 
proved barracks. The Austrian runners also furnish instances 
of breaking down by over-exertion in running at ages un- 
suited for their strength. They seldom live above three or 
four years, and gradually die of consumption (Remains of 
Mrs. Trench, p. 72). In all physical training the condition 
of the heart must be considered not less than the lungs, see- 
ing that its movements respond to the movements of the 
chest and the lungs. They are members of one great system; 
and in nursing one we nurse the other; for by giving tone 
and health to one we must give tone and strength to the other 
(Sibson). If, on the contrary, the development and gradual 
training of the lungs are not successful, the lesions which be- 
come developed are of a peculiar character, and are apt to 



scrofula. * 375 

be thought very lightly of; because, in the first instance, they 
are so little capable of appreciation by a single observation; 
and, secondly, because the lesions are insidious, and take 
some time before they reach a stage to be apparent. 

III. It is important to secure for the patient a uniform, 
sheltered, temperate, and mild climate to live in, with a tem- 
perature about 6o° and a range of not more than io Q or 15 ° ; 
where also the soil is dry, and the drinking-water pure and not 
hard. — The classic work of reference on this topic is that by 
the late Sir James Clark. If it is possible to give a practical 
abstract of his extensive and valuable experience, it may be 
done somewhat as follows: — (1.) After the functions of the 
digestive organs and skin have been re-established in im- 
proved action, the patient who labors under a tuberculous 
cachexia may derive benefit by a residence in a mild or tem- 
perate climate (such as has been defined), conforming to all 
the hygienic and medicinal treatment already mentioned. 
(2.) When symptoms, however slight, indicate that tubercul- 
ous deposit has located itself in the lung, removal to a mild 
climate, -especially if effected by a sea voyage, under favor- 
able circumstances, may still be useful as a means of im- 
proving general health, of lessening the chance of intercur- 
rent inflammatory affections of the pulmonary organs, and 
even of arresting the further progress of the disease. The 
nausea, squeamishness, or even sickness, which with some 
are always more or less associated with a sea voyage, are 
beneficial to cases of incipient tuberculosis. The effects of 
such nausea tend to increase the natural secretion and 
elimination from the pulmonary mucous membrane; so that 
minute portions of tubercular exudation, commencing to 
consolidate in the air-vesicles, are effectually, gradually, and 
gently passed out with the motion of the pulmonary mucus 
in the expectoration. The sensation of nausea tends to sub- 
due any local vascular irritation; and the unceasing motion 
of a sailing vessel tends to keep up a constant exercise which 
is advantageous to the patient. (3.) When extensive tuber- 
culous disease exists in the lungs, little benefit is to be ex- 
pected from a change of climate; and a long journey will 
most certainly increase the sufferings of the patient, and 
hurry on a fatal termination. (4.) There are cases, however, 
of chronic consumption which may derive benefit from resi- 
dence in a mild climate, — namely, cases in which the deposit 
is limited to a small portion of the lungs, and little systemic 
irritation prevails or in cases in which the disease has ceased 



3?6 SCROFULA. 

to extend to the lungs, but where a long time is required to 
complete repair. 

IV. The dress of the scrof hints patient ought to be of such a 
kind as to equalize and retain the temperature of the body. — 
Under this topic waterproof coats, boots, and shoes are to be 
condemned. Flannel ought invariably to be worn next the 
skin in all seasons; and in winter a chamois leather vest may 
be required over the flannel. 

V. The hours of rest should extend from sunset to sunrise. 

VI. Indoor or sedentary occupation must be suspended; but 
outdoor employment in the fresh air, even in the midst of snow, 
has been and may be advantageous. 

VII. Cleanliness of body is a special point to be attended to in 
the hygienic treatment of tuberculosis. 

VIII. Marriage of consumptive females, for the sake of ar- 
resting the disease by pregnancy, is morally wrong and physically 
mischievous. 

IX. The medicinal treatment must be adapted to the site of 
the local scrofulous deposits and the general nature of the par- 
ticular case. — Iron and iodine in various forms are the most 
useful remedies; but medicine is utterly powerless and use- 
less unless the hygienic means now insisted upon are carried 
out to the utmost. 

(c.) Medicinal Treatme?it. — When medicine is required to 
move the bowels, as it often is, nothing serves so well as pow- 
ders of rhubarb, soda, and calumba, taken three times daily, 
or morning and evening only, or an hour before food. Mer- 
cury in any form is not borne by scrofulous patients. Lime- 
water to the extent of half an ounce taken with milk, three 
or four times a day, is of marked benefit in those cases of 
long standing where gland after gland becomes the seat of 
abscess and ulcer (Shapter). The muriate of barytes, next 
to iodine, exerts the most decided influence over scrofula. 
It increases the appetite and the secretions (Adair, Crawford, 
Phillips). The whole class of tonic remedies are of essential 
service; such as, small doses of quinine with conium; iron in 
all its most digestible forms (see under anaemia). The em- 
ployment of acids is often also called for, especially if per- 
spirations become excessive. A useful formula consists of: 

Acid Hydrocyan. dil. 3 i., glycerine ^ii.;acid nitric, dil. 
3 iii., Infus quassiae ad f xiiiss — a tablespoonful for a dose. 

But of all remedies iodine and its compounds are the most 
valuable in scrofula. The following formula is that which 
Dr. Shapter has found most useful: 



SMALL-POX. 377 

3,. Iodine gr. x.; potassae hydriodatis gr. xx., aquae \ \\. 
From 8 to 12 minims are to be dropped into a glass of water 
and taken three or four times a day by an adult. 

It improves appetite and the complexion; subdues the 
general symptoms, and promotes absorption of the scrofu- 
lous glandular swelling. Iodism or iodic saturation must, 
however, be very carefully guarded against. 

Small-pox. — Definition. — Small-pox in man is the pro- 
duct of a specific and palpable morbid poison, which is re- 
produced and multiplied during the course of the malady. 
It is contained in the contents of the pustules, and in the cu- 
taneous and pulmonary excreta of small-pox patients. After 
a definite period of incubation (of about seven to nine days, 
in cases of inoculated, and from ten to thirteen days by ordi- 
nary infection) a remitted fever is established, and followed 
by an eruption on the skin on the third day of the fever af- 
ter forty-eight hours' illness, and sometimes on the mucous 
surfaces. The eruption on the skin passes through the stages 
of papule, vesicle, pustule, scab, and leaves marks or cica- 
trices on its site. The disease runs a definite course, and, 
as a rule, exhausts the susceptibility of the constitution to 
another attack. 

Treatment. — Since the first accounts by the Arabian phy- 
sicians of the ravages of small-pox in Mecca, the history of 
this disease may be considered in three great eras, each of 
which is characterized by remarkable epochs, and a fourth 
may be said to be running its course now. The first of these 
eras is marked by a commencing epoch of improvement in 
the treatment of small-pox. In few diseases has medical 
opinion undergone a more obviously beneficial change, and 
to Sydenham is due the merit of this revolution in medical 
practice. The epoch of the second era is marked by the 
discovery of the singular and beneficial phenomenon that 
the virulence of the poison of small-pox was greatly mitigated 
by introducing or engrafting the disease into the system, 
through the cutaneous tissue, thereby causing the transfer- 
ence of the disease from one person to another, by inocula- 
tion. To Lady Mary Wortley Montague is due the merit 
of having introduced the practice of inoculation into this 
country in 1722— a deed which must be considered as one 
of great heroism, when measured by the knowledge possessed 
by the physicians of those days. The third great era in the 
history of small-pox is marked by the epoch of that remark- 
able discovery which has rendered the name of Jenner im- 



378 SMALL-POX 

mortal — namely, the modifying and protecting influence of 
vaccination. He found that a certain disease in the cow, 
known as the cow pox, could be transferred to the human 
subject by inoculation ; and that, having been so transferred, 
it modified, to a considerable extent at least, the course of 
the disease, if it did not altogether prevent in the human sub- 
ject the occurrence of small-pox in its natural state. A 
fourth era may be said to have commenced in this country 
almost imperceptibly. It may be described as marked by an 
epoch of transition, in which doubt and scepticism have 
arisen as to the efficacy of vaccination ; tending to propagate 
an erroneous popular belief ; and consequently, leading to 
the ineffective adoption of means which practically have 
been proved to be sanative in the highest degree. In other 
countries, on the contrary, and especially in Central Europe, 
this present period is marked by implicit faith in the virtues 
of vaccination, and the successful legal enforcement of this 
sanative measure. The most plausible objections to vaccina- 
tion must now give way before the one great fact that, dur- 
ing the last century, one-tenth of the population died of 
small-pox, while another tenth were disfigured for life by the 
disease ; and that since the introduction of vaccination, the 
general mortality from all diseases is less, and that of small- 
pox is reduced to a minimum. 

An account of the treatment of small-pox resolves itself, 
therefore, into a consideration of two topics, namely, — (1.) 
The usual therapeutic, curative, or sanative treatment of the 
disease ; (2.) The sanitary treatment — /*. e., the means of 
protecting individuals from the small-pox ; or of modifying 
the influence of the malady by inoculation or by vaccination. 
Of these in their order, — 

I. Therapeutic, Curative, or Sanative Treatment of Small- 
Pox. — The main object, in the first instance, is to prevent, 
if possible, a copious eruption ; for the severity and danger 
of the disorder may be measured, in some degree, by this. 
The vulgar belief, that " better out than in," does not apply 
in the case of small-pox. The great object is to reserve the 
strength of the patient ; and the attentions of an experienced 
nurse are demanded. A third indication is to watch for and 
deal vigorously with intercurrent inflammatory action, which 
is apt to be set up. It has hitherto been the belief and or- 
thodox teaching, that the disease is not under the influence 
of any specific or antidote ; that there is no remedy which 
will cut short the disease ; that it must run its course ; and 



SMALL-POX. 379 

that it is the business of the physician to assuage the unto- 
ward symptoms and avert the dangerous accidents which 
may arise, by all the most approved methods of treatment, 
in accordance with the science of medicine of the present 
day. That there are grounds for modifying this belief and 
dogmatic teaching, the following statements will show : — 
The chief physician of Iceland, Dr. J. Hjaltenin, believes 
that it may be stamped out by the action of sulphur- 
ous acid gas ; and relates how, in its malignant 
form, it was so treated, and stamped out of that 
island without a single person of the inhabitants 
becoming infected. The disease was imported into Iceland 
by French fishing vessels coming into the harbor of Rey- 
kjavik, to ask for medical aid; having on board men sick of 
small-pox. Vaccination and revaccination were immediately 
instituted; and government at once erected a quarantine 
hospital, to which the cases were taken from the ships. The 
epidemic showed a high degree of malignancy; and Dr. 
Hajaltelin, being a firm believer in the power of disinfect- 
ants and antiseptic remedies, resolved to try such remedies, 
one after another; the only question being whether 
to use those compounds which acted by oxygenizing or by 
disoxygenizing. He ultimately decided to use the disoxygen- 
ating antiseptics, as being the most safe; and fixed upon 
sulphurous acid as less irritant for the respiratory organs 
than chlorine. He used it externally by fumigation, by 
burning refined sulphur in the sick rooms, and internally by 
giving sulphurous acid mixed with pure water — the usual 
dose being 3 1, mixed with one ounce of water, and repeated 
every third hour. The patients at first disliked the fumiga- 
tion, from the strong and pungent odor of the sulphur; but 
they soon felt its good effects and desired to have more. 
These good effects were, — the heat of the eruptive fever 
diminished, and the vesicles dried very quickly, leaving the 
skin covered with thin brown scales, which soon fell off. 
Out of 22 patients so treated he only lost one, who came to 
the hospital moribund, and who died thirty-nine hours after 
arrival. Seven had confluent small-pox; and of these three 
were in the suppurative stage. Others were cases of discrete 
small-pox having the eruption of vesicles abundant. He 
thus sums up the good effects of the disinfectant method of 
treatment by sulphurous acid externally and internally: — 
(i.) It mitigated the primary and secondary fever; lowering 
the temperature, and thirst was diminished, even when fever 



380 SMALL-POX. 

ran high. (2.) The general symptoms were also lessened in 
severity, such as the headache, backache, and pains in the 
joints. (3.) He believed the sulphurous acid and vapors 
had a destructive influence on the small-pox virus. Its de- 
structive effects on parasite life are undoubted {Brit. Med. 
Journal, Nov. 4. 187 1, p. 519). 

Treatment by Vacci?iation. — There are also some grounds 
for believing that vaccination and the hypodermic injection 
of vaccine lymph " may curb the small-pox," even when 
performed at a period subsequent to the reception of the 
variolous poison: and the observations and practice of Mr. 
R. C. Furley, detailed in the British Medical Journal for 
June 8, 1872; show that vaccination will modify small-pox 
after the eruption has appeared. An impression prevailed 
that it was dangerous to be vaccinated while small-pox was 
prevalent; and also that it was of no use to vaccinate so 
long as the former vaccination mark was quite distinct. 
Both these ideas are opposed to facts. On the contrary, 
Mr. Furley's cases show that vaccination, and the injection 
of vaccine lymph, especially if done about the second or 
third day of the disease, possess valuable curative powers, so 
that a disease which promises to be most severe is curbed or 
modified. Mr. Furley uses a hollow needle for injection, the 
bore of the tube of which is large enough to admit a vaccine 
tube, from which the lymph is forced directly into the circu- 
lation. He injects hypodermically in both arms. 

Dietetic and General Treatment. — In the first instance, the 
course to be pursued is for the physician to act on the de- 
fensive, and simply protect his patient from certain injurious 
influences to which he may be exposed, — such as, heating 
drinks to force out the eruption, which are apt to be given 
by ignorant and officious friends. Throughout the whole 
course of the disease, the diet should be strictly limited to 
slops, sago, arrow-root, and ripe fruits, with cold water or 
letnonade for drinks, with or without ice. The chamber in 
which the patient lies should be cool, not above 6o° Fahr., 
and freely ventilated. The bed-clothes should be light, the 
body-linen daily changed; and, when the disease is long, the 
patient's back should be often examined to prevent slough- 
ing. The scalp, likewi.se, should be examined, and, if full of 
pustules, the hair should be cut off, to prevent its matting. 
If the disease be recognized early, however, it is proper to 
shave the scalp, because the irritation which attends the 
suppuration of the pustules is thereby diminished, and cold 



SMALL-POX. 381 

may bs more efficiently applied to the head, if necessary. 
In the early stage of the primary fever, in severe cases more 
especially, it is necessary to have the bowels well opened in 
the first instance, and to keep them regularly moved daily by 
saline medicine, or an enema of three parts water to one of 
vinegar. A cathartic pill, composed of the following in- 
gredients, will be found to be efficient in most cases, especi- 
ally if aided by a Seidlitz power, given six or eight hours 
after the pill; namely, — Two grains of calomel, one grain of 
the compound extract of colocynth, one grain of gamboge, 
and one grain and a half of scammony, made consistent Avith 
a little aromatic oil The bowels must be daily attended to, 
and castor-oil, or rhubarb, or magnesia, may sometimes be 
required. Saline diaphoretics, in the form of James's powder; 
of the aqua acetatis ammonise, to which a grain or two grains 
of tartar emetic has been added, so as to have ^ or -^ of a 
grain in every tablespoonful of the mixture, is an efficient 
and cooling diaphoretic. Spirit of nitric ether, or the nitrate 
of potass, may be added if required. The surface of the 
body, over the hands, face, and feet, ought to be sponged 
several times a day with tepid water mixed with Condy's 
fluid, or with sulphurous acid, with a view to relieve the 
intolerable itching; but caution is necessary to prevent ex- 
posure to cold. Cold-cream, or a liniment of olive oil, 
glycerine, and lime-water, or of Carron oil (linimentum aqua 
calcis), smeared from time to time over the itching surface, 
by means of a camel-hair pencil, may be found to afford re- 
lief ; and chlorine lotions are highly spoken of by Eisenmann. 
With regard to the occurrence of convulsions in children, it 
is not found that opiates, as recommended by Sydenham and 
Cullen, are expedient. When the children are robust, or 
previously in good health, local bleedings, by means of one 
or two leeches to the temples, are more beneficial. Delirium, 
violent screaming, intolerance of light or sound, heat of 
head., all of which indicate a tendency to meningeal conges- 
tion, still more clearly warrant the application of leeches. 
With regard to the propriety of bleeding (general) in adults, 
it is now well ascertained that it will neither eradicate the 
fever nor diminish the amount of the eruption; moreover, 
experience has now amply shown that loss of blood is badly 
borne in all infectious diseases. The persistent application 
of cold to the head, and repeated affusion of the body with 
cold water, is to be preferred, in cases where there is much 
cerebral excitement. When delirium, with restlessness, 



382 SMALL-POX. 

wakefulness, and a frequent pulse, is continuous, an opiate, 
or the free use of alcoholic stimulants, are indicated; and 
opium is most advantageously given combined with tartar 
emetic. A draught, composed of thirty minims of the solu- 
tion of muriate of morphia, with half a grain of tartar emetic, 
will be found beneficial in such conditions, especially when 
given at bed-time. If the temperature rise higher, large doses 
of quinine, 3 to 5 grains, every three or four hours, are to be 
given. Cooling drinks, with or without ice, of lemon-juice, 
tamarinds, neutral effervescing powders, are always agreeable 
to the patient, who ought, for the sake of coolness, to be 
very lightly clothed. After the eruption has fully appeared, 
this is all which in ordinary cases requires to be done, and 
if, towards the tenth or eleventh day, there is much restless- 
ness or sleeplessness, an opiate may be given. 

In the complications which sometimes ensue, such as in- 
flammation of the throat and base of the tongue, opiates are 
found to be injurious. The general treatment must be by 
cathartic or purgative clysters, if swallowing is difficult. In 
the other inflammations, however, opiates are of the greatest 
service, provided the symptoms be not those of cerebral op- 
pression or bronchitis. In bronchitis, nauseating doses of 
antimony every hour sometimes procure relief; and if reljef 
does not follow in the course of thirty to thirty-six hours, 
stimulant doses of mistura ammoniac with squills ought to be 
given every second hour to promote free expectoration. 

In the advanced stage of the secondary fever the strength 
of the system requires maintenance and support; because 
the abundant suppuration and extensive cutaneous irritation 
combine to exhaust the strength, as shown by the weakened 
pulse, the dark and dry tongue, blueness, paleness, or cold- 
ness of the extremities. Tonics, stimulants, and generally 
nutritious diet, are now called for. Quinine, mineral acids, 
malt liquors, especially the light bitter ales, light porter, wine, 
and even brandy, may be demanded. The diet should con- 
sist of milk, strong animal broths, eggs, raw or lightly boiled, 
according to the discretion of the physician, and regulated by 
the digestive powers of the patient. 

The development of a severe eruption on the conjunctiva 
is to be especially guarded against, by the assiduous employ- 
ment of cold water applications, or by compresses moistened 
with a weak solution of corrosive sublimate (one grain to six 
ounces of water, with or without the addition of muriate of 
ammonia (Niemeyer). 



SMALL-POX. 383 

To prevent the face from being seamed, scarred, or 
"pitted " by the suppuration of the pustules, has taxed the 
ingenuity of physiologists and physicians. It has been stated 
that the influence of the atmospheric air is essential to the 
development of ths pustules, and, accordingly, anything 
which would effectually exclude this influence would prevent 
the occurrence of a scar. But it is evident that the chance 
of scars can only be diminished by those means which are 
calculated to allay the general violence of the disease. When 
the eruption is severe, it is almost impossible to prevent the 
formation of " pits," because the depression results from the 
expulsion of a small slough; and the more mild the suppura- 
tive inflammation can be rendered, so in proportion will the 
chance of sloughing, and therefore "pitting" be dimin- 
ished. 

The local means, which have been adopted to prevent 
"pitting" may be shortly stated as follow: — (1.) To open 
each individual pustule after suppuration has commenced. 
(2.) To cauterize the pustules with nitrate of silver. (3.) To 
employ both methods — that is, to open each of the pustules 
when it becomes vesicular, and introduce a strong solution of 
nitrate of silver into the cavity of the vesicle. At the end of 
a week scales fall off, and no pit is left. Or, lastly, to paint 
the face with a solution of nitrate of silver, in the proportion 
of one drachm of the nitrate to the ounce of water. (4.) The 
application of a mercurial plaster, with the view of producing 
resolution of the papulae. The preparation in use for the 
purpose at the Children's Hospital in Paris consists of twenty- 
five parts of mercurial ointment, ten parts of yellow wax, six 
parts of black pitch. With this plaster the face is to be cov- 
ered, and so to remain for several days, (3.) Sulphur oint- 
ment, applied several times a day. (6.) Calamine mixed with 
olive oil, to form a coherent crust (Bennett). (7.) Tincture 
of iodine, painted over with a brush. (8.) Saturated solution 
of gutta percha in chloroform (Drs. Graves and Wallace). 
(9.) To smear the face over with common olive oil. (10.) 
Skoda prefers compresses moistened with solution of corro- 
sive sublimate (two to four grains in six ounces of water) to 
mercurial plaster, which induces too much elevation of tem- 
perature. (n«) Hebra recommends cold water compresses 
only. 

All of these applications have been for the most part, ap- 
plied to the face, the hands, and the arms only 

The severity and the mortality of small-pox have led many 



384 SMALL- POX. 

to think of means by which the disease might be completely 
extirpated. This leads to the consideration of — 

II. The Prophylactic, Sanitary, or Preventive Treatment of 
small-pox. — More than half a century ar^o it was generally 
taught, among English physicians, that small-pox attacked 
the same individual only once in the course of life, and that 
its double occurrence in the same person was either very rare 
or next to impossible. The observations of Drs. Willan, John 
Thomson, Mr. Cross, Dr. Barnes, Dr. Craigie, and others 
since the time of these eminent physicians, lead to the follow- 
ing general conclusions : — (1.) Small-pox, though in general 
attacking the same individual onlv once during the course of 
life, may, however, affect him a second, and even a third 
time. (2.) This happens much more commonly when the 
first attack has been one of mild distinct small-pox, than 
when it has been severe ; and if the first attack has been one 
of confluent small-pox, it is rare for the same individual to 
have a second attack. (3.) It is established by numerous ob- 
servations, that an attack of any one of the varieties which 
have been named spurious small-pox, or abortive small-pox, 
or chicken-pox, by no means secures the same individual from 
an attack of confluent small-pox at a subsequent period. (4.) 
Small-pox produced by inoculation does not necessarily se- 
cure the individual against an attack of small-pox induced in 
the natural way. (5.) Every previous attack, however, of 
small-pox, whether natural or inoculated, exercises some 
modification on that which succeeds. This modification may 
be various in degree, from very slight and almost impercepti- 
ble to very conspicuous and remarkable. In this modifica- 
tion the symptoms of eruptive fever may be mild and of 
short duration ; and the eruption may consist of vesicles or 
hard pustules, which disappear without suppuration. (6.) 
The most powerful modifying agent on the course of 
small-pox is the action of the cow-pox on the 
constitution, or the disease produced by the appli- 
cation of vaccine lymph to the exposed skin. The specific 
disease so induced, in a large portion of cases, not only ren- 
ders the individual less likely to be affected by the variolous 
effluvia, but, if he is affected, changes very much the charac- 
ters of the disease which may supervene. Though the fever 
which precedes the eruption in cases of this class be similar 
in form and equal in degree to that by which the inoculated 
small-pox is attended, the eruption is either papuliform or 
tuberculaled, without much surrounding inflammation. A 



SMALL-POX. 385 

similar eruption is produced when vaccine and variolous mat- 
ter are inoculated at the same time in the same individual; 
or when a person who is exposed to the variolous contagion 
has been inoculated with vaccine lymph early enough to mit- 
igate, but not wholly to supersede, the eruption of small-pox. 
In such circumstances the vaccine lymph and variolous mat- 
ter restrain and counteract the operation of each other on 
the system and on the skin. To these eruptions of modified 
small-pox the general name of varioloid eruptions has been 
applied. (7.) Cow-pox destroys the susceptibility to inocu- 
lated small-pox almost entirely; but the susceptibility to the 
natural disease, or that by inhalation, it does not entirely ex- 
tinguish. This susceptibility, however, it diminishes in a 
much greater degree, and "much more effectually, than in- 
oculated small-pox does. (8.) The susceptibility to second 
attacks of small-pox,* and attacks of small-pox after vaccina- 
tion, is principally favored by the existence of an epidemic 
constitution of the atmosphere, and by the circumstance of 
early life, or the age below ten years. If no epidemic influ- 
ence exists, the occurrence of second attacks of the disease 
may not be observed for a long series of years. But if, on 
the other hand, the atmosphere should possess or acquire an 
epidemic or variolous constitution, then neither the circum- 
stance of a previous attack of small-pox, nor vaccination, 
can insure many of those under ten years of age, and not a 
few between that and thirty, from attacks of small-pox. 

The preventive management of small-pox consists: (1.) 
In the artificial production of the disease by inoculation, or 
artificial variolation. (2.) In the modifying and protective 
influence of vaccination. 

Inoculation consists in the application of small-pox matter 
or virus to the surface of the corium, exposed by a puncture 
or scratch. The result is a local inflammation similar to 
small-pox, attended with an eruption and a fever, generally 
milder in form than small-pox acquired by breathing an at- 
mosphere contaminated with the specific poison of the dis- 
ease. The poison thus passes through the mucous mem- 
brane to infect the blood; and hence this is called the "nat- 
ural way" of contracting small-pox. For obvious reasons, 
the operation of inoculating the poison of small-pox has been 

* The average number of second attacks of small-pox seems to be one 
percent. (R. Acad, of Med., Marseilles, 1828 ; and B. and F. Med.- 
Chir. Review, Jan., 1848, p. 74). * 

25 



386 SORE THROAT, CLERGYMAN'S — ST. VITUS' DANCE. 

rendered illegal in this country, and the practice of vaccina* 
tion has been attempted to be enforced by law. 

Sore Throat, Clergyman's— See Pharyngitis, Chronic. 

Sore Throat, Sloughing. — Definition. — Idiopathic 
ulceration of an acute form, attacking the tonsils and rapidly 
running into sloughing of the fauces. 

Treatment. — In all cases of sloughing sore throat a stimu- 
lating and tonic treatment must be pursued. Tincture of 
the perchloride of iron, quinine, and chlorate of potash, are 
the most suitable internal remedies. Disinfecting gargles of 
carbolic acid or permanganate of potash are not only agree- 
able to the patient, but very useful in checking the offensive 
discharges. 

Spasm of Muscle — See Muscle, Spasm of. 

Spleen, Inflammation of— See Splenitis. 

Splenitis. — Definition. — A primary acute inflammation 
of the substance of the spleen. 

Treat7nent. — Bleeding in splenitis will not effect a cure, 
while mercury is most pernicious. A spleen mixture, not 
dissimilar to that recommended by Celsus, is most in vogue 
in India. The best, according to Mr. Twining, consists of 
the following: 

I)L Pulv. Jalap.; Pulv. Rhei.; Pulv. Calumba; Pulv. Zin- 
gib; Potass. Supertart, a a 3 j.; Ferri Sulphat., 3ss.; Tinct. 
Sennse 3ss.; Aquae Menthse Pip., 3 ixss. Of this mixture 
an ounce or an ounce and a half is to be taken twice a day, 
or such quantity as may produce three or four stools in the 
twenty-four hours. 

The iodide of potassium and the bromide of potash have 
been more recently recommended. The dose of the bro- 
mide of potash is gr. v. to x. ter die, combined with camphor 
mixture. The marked influence of the biniodide of mercury, 
in the form of an ointment rubbed into the skin over the 
surface of a goitre, in reducing its enlargement, has been al- 
ready noticed. It has been similarly used in cases of en- 
larged spleen ; and the invalid soldiers who suffer from 
enlarged spleens invariably apply for some to take away with 
them when they are discharged from Netley Hospital. 

Spinal Cord, Inflammation and Suppuration of— 

See Encephalitis. 

St. Vitus' Dance— See Chorea. 



STOMACH, CHRONIC ULCER OF. 387 

Stomach, Chronic Ulcer of. — Definition. — Inflamma- 
tion of the stomach, ending by loss of substance in the form 
of an ulcer. 

Treatment. — Chronic ulcers are to be treated by rest to 
the stomach, and by dietetic rather than by medicinal means. 
The patient must eat in small quantities, especially of milk 
compounded with arrow-root, macaroni, semolina, sago, 
tapioca, biscuit powcer, barley meal, Indian meal, or oat- 
meal gruel. Iced milk, combined with one-quarter to one- 
third of lime-water, is particularly recommended, two or 
three tablespoonfuls of which are to be taken at short in- 
tervals; so that about two quarts of milk may be thus used 
during the day; rendering regular and more bulky meals un- 
necessary. The lime-water tends to prevent coagulation, 
and the milk more readily passes unaltered into the intes- 
tines, to be digested by them rather than by the stomach. 
The most complete rest possible ought to be given by stop- 
ping the supply of all nutriment by the mouth, and support- 
ing the patient for several days by nutritive enemata. Per- 
fect quiet in the recumbent posture must be observed, the 
lips and tongue being moistened from time to time by a 
little water. The patient may thus be kept for eight or nine 
days, or even longer, on nutrient enemata alone, when the 
pain, the irritability of stomach and of the system will cease. 
The substances most useful for enemata are milk, strong un- 
salted beef-tea, raw eggs beaten up in milk, occasionally a 
little brandy, and (generally in two enemata daily) ten or 
twenty minims of tincture of opium. The enemata should 
be as small as possible, from two to six ounces only at a 
time. The interval to the stomach thus gained of complete 
rest is of the greatest importance towards success in the 
treatment of gastric ulcer; and, combined with the restricted 
diet described, will usually effect a cure in three weeks (Dr. 
Balthazar W. Foster, of Birmingham, Brit. Med. Journal, 
June 3d, 1865). Next to dieting, blood-letting by two or 
three leeches, applied to the region of the stomach about 
twice a week, affords obvious benefit. Blistering applied to 
the spine may relieve the dorsal pain. Small lumps of ice 
may be swallowed if the stomach is irritable; and astringent 
remedies, especially the salts of metals, such as a combina- 
tion of iron and alum, are of use; and gallic acid, nitric acid, 
and bitter barks may be administered. Constipation is to 
be counteracted by enemata. When haemorrhage occurs, 
small bits of ice may be swallowed, and rest maintained in 



388 STOMATITIS. 

the horizontal posture. Astringent medicines are to be ad- 
ministered, such as oil of turpentine, acetate of lead and 
opium, alum and tannic acid. Oil of turpentine should be 
given in doses varying from ten to twenty minims in cold 
water, and repeated more or less frequently according to the 
urgency of the symptoms. Ergot may also be employed. 
When haemorrhage is copious, a mixture containing ten 
minims of diluted sulphuric acid and five grains of gallic 
acid in water, taken every two or three hours, is the best 
remedy (Dr. B. Foster). Vomiting may be relieved by dilute 
hydrocyanic acid (five minims), combined with bicarbonate 
of soda (twenty or thirty grains) in solution, repeated every 
two or three hours. The subnitrate of bismuth, in doses of 
ten to twenty grains, every six or eight hours, alone or com- 
bined with five to ten grains of compound powder of kino, 
has a remarkable effect in relieving pain, vomiting, and 
diarrhoea (Brinton). Seller's bismuth mixture is also an 
efficient remedy. 

Stomatitis. — Definition. — Inflammation of the mouth. 

Treatment. — The mouth should be frequently washed with 
emollient fluids, such as linseed infusion, diluted glycerine 
and biborate of soda, or honey mixed with biborate of soda. 
The following lotion may be painted over the lips and 
mucous membrane of the mouth and tongue, namely: — 
Sodae Biboratis, fl. dr j.; Glycerini, fl. oz. ii.; Aquae Rosse, fl. 
oz. iv. ; misce (Tanner). Creasote, vinegar, carbolic acid, 
glycerine, and alcohol are also recommended as local appli- 
cations. The late Dr. Symonds, of Bristol, recommended 
combinations of turpentine, with glycerine and alcohol; 
equal parts of turpentine and glycerine, applied with a soft 
brush two or three times a day, being, in his opinion, a 
curative application, whether the lining of the mouth be red 
and puffed, or pale and oedematous, or studded with super- 
ficial ulcers, or opaque yellow accumulation of secretion or 
epithelium. He also recommended that follicular ulcers on 
the inside of the lips and cheeks and tip of the tongue should 
be treated by sulphate of copper applied once or twice a day 
{Brit. Med. Journal, March 13th, 1868). In severe cases, 
where the breath becomes fetid, with the submaxillary glands 
large and swollen, the lips and gums tumid, the face flushed 
and swollen, and the fever intense, chlorate of potash must 
be freely given internally, to the extent of five grains every 
four or six hours. Besides these remedies, the solution of 
the pernitrate of iron, internally, has a beneficial effect upon 



STOMATITIS, GANGRENOUS SUNSTROKE. 389 

the sores, prescribed in the following formula: — Liq. Ferri. 
Pernitratis, gtt. xl.; Syrup. Aurant, fl. oz. ss.; Aquae, fl. oz vss.; 
misce. A fourth part may be given to a child three or four 
years of age four times a day (Dunglison). In cases where 
parasitic vegetable productions abound (parasitic thrush), 
the application of a solution of sulphite of soda (fl. dr. i. to 
fl. oz. i. of water) removes the deposit in twenty-four hours 
(Jenner). The secretions of the mouth being acid, the salt 
is decomposed, and sulphurous acid is set free, which de- 
stroys the parasite. A change of air is often absolutely 
necessary to restore the patient to health; and arsenic and 
iodine, combined with good diet, are useful restorative 
agents in repairing the faulty nutrition of the child. 

Stomatitis, Gangrenous — See Cancrum Oris. 

Struma — See Scrofula. 

Sunstroke. — Definition. — An affection of the nervous 
system associated with vertigo and sometimes with head- 
ache, or the gradual accession of listlessness and torpidity, 
with a desire to lie down (Longmore, Barclay). These fe- 
brile phenomena may culminate in more or less sudden in- 
sensibility, without the power of sense or motion, the breath- 
ing rapid, and getting more and more noisy as death ap- 
proaches. Convulsions of the extremities when in a com- 
plete state of coma, in which the patient gradually dies. The 
approach of death is indicated by the failure of the heart's 
action, the fluttering of the pulse, the irregularity of the res- 
piration; and the fatal event may supervene within five min- 
utes to a few hours after the disease has become fully' ex- 
pressed. Death is either by syncope, apncea, or by a com- 
bination of the two. In cases which recover, various seque- 
lae are apt to supervene, such as forms of paralysis, more or 
less complete, choreic movements, melancholia, and other 
forms of disorder of the intellect. 

Treatment. — Keeping in view the nature of this disease, 
and the various modes in which death may approach, the 
line of treatment may be indicated as follows: 

With regard to the class of cases in which death tends to 
occur suddenly from syncope, there is little opportunity af- 
forded for treatment; but the measures indicated are, — re- 
moval to a cooler place, if possible, as from the engine-room 
or stoker's place onboard steamships to the open deck; the 
cold douche, but not too prolonged; keep the surface wet 
and exposed to a current of air, or assiduously fanned: ex- 



390 SUNSTROKE. 

elude light as fai as possible; remove or loosen tight and 
oppressive clothing; the immediate employment of stimu- 
lants, external and internal, by the rectum as well as by the 
mouth, and ammonia to the nostrils. Depletory measures 
of any kind are not to be thought of. In the less rapidly 
decisive cases prompt treatment is of the greatest use, while 
delay is fraught with the greatest danger. The patient must 
be immediately stripped of his outer clothing; and, being 
placed in a semi-recumbent position, the cold douche is to 
be applied, from a height of three or four feet, over his head 
and along his spine and chest, his extremities being at the 
same time sponged over with cold water. Relaxation of the 
pupil is the first symptom that shows the good effect of the 
treatment, which may require to be repeated several times, 
on account of returning insensibility; but if there is any evi- 
dence of failure of the pulse, this treatment must be discon- 
tinued, and the application of cold to the head is then all 
that can be borne. Stimulants administered by the rectum 
are recommended by Dr. Levick, to counteract the tendency 
to prostration. In some cases in India rousing by flagella- 
tion with the sweeper's broom was had recourse to with good 
effect by Sir Joseph Fayrer. The hair is to be cut short as 
soon as possible, and a blister applied to the nape of the 
neck, the surface having previously been well sponged over 
with the acetum lyttse. When the first violence of the attack 
is subdued, increasing confidence in the ultimate result may 
be indulged in so soon as vesication takes place; and in 
cases where insensibility recurs, after an interval of ten or 
twelve hours, it may be removed by the application of a 
second blister to the vertex; which may even be again re- 
peated, there being no doubt as to the good effect it pro- 
duces. Sir Joseph Fayrer, on the other hand, expresses a 
want of faith in their efficacy. A blister may also some- 
times be applied along the spine in the worst cases. Stimula- 
tion by the use of the electro-galvanic current, with the 
moist sponges applied along the sides of the neck, chest, 
epigastrium, ought also to be employed. Sinapisms ought 
generally to be applied to the extremities, and to the chest 
or sides. 

As soon as possible after the employment of the douche, 
a strong purgative enema ought to be given, those of a stim- 
ulant nature being preferred. But as the enema may have 
to be repeated several times before any effect is produced 
on the bowels, it may be advisable to let the first enema be 



SUNSTROKE. 



39* 



of a simple purgative character, and afterwards let it be fol- 
lowed up by turpentine enemata. 

If cerebral congestion is indicated by the state of the eyes 
already described, a few leeches to the temples may relieve 
the congestion (Longmore, Barclay); but the prevailing 
opinion among medical officers of experience in the treat- 
ment of this disease is against the employment of blood-let- 
ting by venesection, even in severe cases. In all the cases 
which have been recorded in which it has been employed, it 
seems to have been generally hurtful, and to have hastened 
the fatal termination. In cases when it has seemed at first 
to give relief and to mitigatethe symptoms, the improvement 
has been only transient, and followed by relapse into a more 
dangerous and fatal condition. But no absolute rule can be 
laid down in regard to abstraction of blood. There are 
cases in which it may be necessary, in order to avert suffo- 
cation; but they are the exception, and it is possible there 
may be more danger to life in the laboring and distended 
heart and the embarrassed lungs, than in the loss of a few 
ounces of blood; which, if it would have tided the patient 
over the danger, as it sometimes might do, would be the 
lesser evil, and as such should be chosen. Each case must 
be treated on its own merits (Sir Joseph Fayrer). 

In cases where the breathing is much oppressed, and the 
bronchial tubes loaded with mucus, the -patient should be 
turned occasionally over on his face and side. In the con- 
vulsive form of the disease, where the greatest irritability of 
the nervous system prevails, the douche is found to be inad- 
missible, from the agony which it occasions. In such cases 
Dr. Barclay has seen great benefit from the inhalation of 
chloroform. After a few inspirations the convulsions for the 
most part ceased, and sleep was very easily induced; but in 
one or two instances 5 after a considerable interval of con- 
sciousness, febrile symptoms increased in severity, coma 
supervened (probably effusion having occurred within the 
cranium), which was followed by death. But the cases in 
which chloroform can be used are comparatively few; and 
very great care is necessary in its employment, so that the 
inhalation may be suspended at once, as soon as any effect 
is produced upon the pulse. 

In the most severe forms of the disease the principle of 
management is to reduce as quickly as possible the blood- 
heafc, and that before, tissue changes have begun. As the 
hyperpyrexia is due not only to the direct operation of heat 



39 2 SUNSTROKE. 

on the nerve centres, blood, and tissues, but to the fever 
set up by vaso-motor disturbance, those remedies are 
indicated which have been already mentioned as useful 
for the reduction of temperature. The unduly heated blood 
is a poison for the cardiac and vaso-motor centres tend- 
to cause death, either by syncope or asphyxia. This 
is best effected in sunstroke by rubbing the body over with 
ice, as large as can be handled, as recommended by Dr. 
Levick, and as has been proved to be successful by Baumler 
and Dr. Woodman at the London Hospital. Tepid body 
baths, with cold affusion to the head and back of the neck, 
or general cold affusion, may be employed; also, injections 
of iced water. Keeping pieces of ice in the axilla until there 
is returning consciousness, which may not be for several 
hours, and, therefore, great caution is required in such use 
of ice, so as not to induce gangrene of the skin, or continued 
depression, as indicated by a thermometer in the mouth, 
axilla, or rectum. 

The sequelae of sunstroke are generally, persistent head- 
ache, fixed or shifting pain in the back, choreic movements 
of the forearm and hand, convulsive disorders, mental weak- 
ness. These symptoms are suggestive of hsematoma of the 
dura mater, as a probable lesion in such cases, and indicate 
rest, attention to the functions of the skin, and change of 
air ? and removal froni a hot to a cold climate. All stimu- 
lants and all excesses of diet, or errors in diet, are to be spe- 
cially guarded against. When the pain is fixed and severe, 
long-continued counter-irritation at the nape of the neck, 
and a course of iodide of potassium, may benefit the patient; 
but many cases are quite unrelieved by treatment, as the 
records of the invaliding hospital at Netley show every year 
(Dr. Maclean). 

Measures for the Prevention of Sunstroke. — (i.) If a march 
is to be undertaken during hot weather in India, all weak 
and sickly men should be weeded out and left behind. (2.) 
The costume should be suitable for the early morning hours 
before sunrise, as well as for the scorching period which fol- 
lows, when the men are for the most part in their tents. It 
should consist of materials of slow conducting power, of a 
color by which heat is not readily absorbed, and its fitting 
should be as loose and light as possible. A flannel shirt 
should be worn, to prevent exposure to sudden chills, and a 
flannel belt round the loins may be worn with advantage, 
except in the hottest weather. The shirt-collar should either 



SUNSTROKE. 393 

be open, or made so wide as to prevent all risk of its press- 
ing injuriously on the veins of the neck. Above all, some 
form of knapsack should be devised other than that hitherto 
in use. The authorities, strongly urged by the late Dr. 
Parkes, have adopted a valise equipment, which is a great 
improvement on the older knapsack, and Surgeon-Major W. 
S. Oliver has devised another, which has also been favorably 
reported upon. Both of them do away with the use of cross- 
belts, so injurious to the functions of the organs within the 
chest. The march ought not to commence too early in the 
morning. The troops should be on the new ground about 
an hour after sunrise, and the pace should never exceed 
three and a half miles an hour. There should be a halt for 
seven or eight minutes every hour, or oftener, if the men are 
exhausted; and a longer halt half way, when each man should 
have a cup of coffee and a biscuit. They ought also to have 
their ration before starting in the morning. An ample sup- 
ply of water should be provided for the men by " bheesties " 
attached to each company, and always compelled to march 
with it. No man should be allowed to fall out without be- 
ing accompanied by a non-commissioned officer, who should 
bring him to a medical officer at once if sick, and if not, he 
should bring him up to the column at the halt. All men so fall- 
ing out should be brought up to hospital tents for examination 
immediately on the arrival of the regiment in camp. The men 
should carry nothing on the march but their rifles and am- 
munition — the quantity of the latter being kept as small as 
is consistent with safety. They should be allowed to march 
" easy " and loosely clad, more particularly in passing 
through jungles or ravines. No halt should ever take place 
on such ground when better may be had within a moderate 
distance. When the sun is up, halts should be so timed that 
shelter may be obtained by open topes. Camps should be 
formed on as high and open ground as possible. The sites 
for camps in India marked out by the " official " pillars, are 
generally the most objectionable that could have been select- 
ed (Barclay, Indian Sanitary Commissioners, and others). 
As much space should be allowed between the tents as the 
ground will admit of. Tents should be pitched as speedily 
as possible, camels and elephants being provided for their 
transport — carts never. " Kus-kus " mats should be kept 
constantly wet. 

Troops in the field during the continuance of the hot 
winds in India should have the best description of tents that 



394 SUPRA-RENAL CAPSULE DISEASE — SYPHILIS. 

can be got for hospital purposes, and be provided with the 
best known means for keeping them cool. An abundant 
supply of water in camp is of the utmost importance, care 
being taken that the bags containing it are in good repair, 
hung up within easy reach of the men, and kept always filled 
with water. Sentries should be under cover during the 
heat of the day; and the men should be instructed, when- 
ever they go out in the extreme heat of the sun, to put a 
wetted towel or thick handkerchief over the head, under 
the cap, and around the back of the neck and face. The 
men should be encouraged to take exercise during the 
cool of the evening; or, at all events, to leave their tents, so 
as to permit of their thorough ventilation; and wherever it 
is practicable, bathing should not be omitted. Rations of 
spirits ought to be discontinued in India. It may be a ques- 
tion as to what should be substituted instead; but all author- 
ities are agreed that the system of " spirit rations " tends to 
convert young soldiers into drunkards. The sleeplessness, 
which sometimes is a premonitory symptom of the disease, 
rn^iy be relieved by chloral hydrate combined with bromide 
of potassium, followed by a purge. 

Supra-Renal Capsule Disease — See Addison s Disease. 

Syphilis. — Definition. — The result of a specific living 
poison ; or, of (l a something " of an uncertain nature, but ca- 
pable of self-multiplication, which breeds in the blood and 
tissues, which is introduced into the system solely by con- 
tagion, inoculation, or implantation on some part of the body 
of a healthy person, — i. e., a not yet syphilitic person, gener- 
ally through an abrasion or sore consequent on sexual inter- 
course with an infected person (acquired syphilis), or by in- 
heritance (congenital syphilis). Three weeks or a month 
after contagion and absorption of the poison, a peculiar se- 
ries of phenomena begin to show themselves, which mark 
the general infection of the system, namely, — First, a distinct 
specific fever is followed by or attends the development of ; 
Second, the principal anatomical signs of general infection, 
which consist of — (a.) induration (specific) round the spot 
where the virus has been implanted ; (o.) induration of the 
•lymphatic system of glands ; (e.) the development of a cu- 
taneous and mucous exanthem ; (d.) the formation of nodes 
or gummatous nodular tumors in the connective tissue gen- 
erally, and especially in that of the true skin, bones, mucous 



syphilis. 395 

membranes and solid visceral organs, e. g., liver, brain, lungs 
and heart (visceral syphilis) ; (e.) a cachectic condition of the 
system which follows and accompanies the phenomena of in- 
fection ; and (/.) indurations which may remain in the form 
of hardened fibrous tissue in various parts of the body for an 
indefinite period of time. The whole course of the disease 
is characterized by slow, but progressive development, often 
marked by periods of recrudescence. 

Treatment. — (a.) Preventive. — There are certain facts 
which must be kept in view in the consideration of prophy- 
laxis, (i.) The disease spreads principally by sexual inter- 
course ; (2.) prostitution is the source whence the syphilitic 
virus is ever freshly drawn, and the experience of thousands 
of years has shown prostitution, alike in the ancient and the 
modern world, to be an unavoidable evil, the suppression of 
which is impossible ; (3.) with the intimate relations existing 
at the present day between all parts of the world, and the 
unbounded intercourse between different places at home and 
abroad, which has been developed in recent times, syphilis is 
constantly being transported from one place to another. In 
the interest of public health it is the duty of the State not 
only to limit prostitution, but to exercise a supervision 
over it. 

Keeping these facts in view, there are other facts which 
suggest the direction in which preventive methods for re- 
pressing the extent of syphilis ought to be persistently car- 
ried out, namely : — (1.) Official supervision over prostitution 
has had the most favorable influence in diminishing syphilis. 
This is shown in many ways: — (a.) Everywhere it is found 
that secret, unwatched prostitution is far more active in the 
spread of syphilis than prostitution which is under control ; 
\b.) In 1866, the second Contagious Diseases Act was 
passed, after long and careful consideration, and is the one 
now in force. In the Army Medical Department Report for 
1875, it appears that during three years immediately preced- 
ing the operation of those Acts, the average annual ratio of 
cases of primary and secondary forms of disease was 104.4 
per 1,000. whereas in 1875 it did not exceed 45.8, and in the 
period from 1870 to 1878, the average rate of prevalence of 
the disease fell to 44 per 1,000 men ; and further, it appears 
that the ratio of primary disease was 53.4 in 1866, but in 
1875 it had declined to 33.5. (c.) Through the courtesy of 
Sir W. M. Muir, K.C.B., the Director-General of the Army 
Medical Department, I am able to give the results for 1878. 



39^ SYPHILIS. 

At fourteen stations under the Act, the average annual 
strength of the troops was 53,813, among whom admissions 
for primary venereal sores averaged 40 per 1,000, and 78 per 
1,000 for gonorrhoea. On the other hand, at fourteen other sta- 
tions not under the Act, the average strength of the troops 
being 45,316, the ratio of admissions among them was 86 per 
1,000 for primary venereal sores, and 121 for gonorrhoea. 
Thus, at the stations not under the act, the average rate of 
admission for both forms of disease was 103.5 per 1,000, as 
against 59 at the stations under the Act. At these* fourteen 
stations under the Act, the highest rates of admission for 
primary sores were 53 and 54 respectively per 1,000, at 
Aldershot and the Curragh ; whereas at the fourteen stations 
not under the Act the rates of admission for these diseases 
ranged upwards to 140 in Warley, 154 in Dublin, 205 in 
Manchester, and 250 in London. So with regard to gonor- 
rhoea, the highest rate among, the fourteen stations under 
the Act was no at Winchester per 1,000 ; whereas, at the 
fourteen stations not under the Act it ranged upwards 
to 151 in London, 161 in Warley, 163 in Sheffield, and 177 
in Manchester, per 1,000. (d.) In unprotected [The 
term unprotected district is meant to include the principal 
cities of the United Kingdom where women can practice 
prostitution in any public thoroughfare, at- any hour of the 
day or night, without hinderance, and inveigle men to their 
homes ; and this, too, under the very eyes of the authorities, 
who are powerless to interfere unless the solicitation be to 
the annoyance of any passenger or householder, who must 
in that case accompany the police to the station to charge 
the woman with the offence, which is rarely or never done. 
Should the authorities have credible evidence that the woman 
so conducting herself is suffering from a contagious disease, 
which she may communicate to others having relation with 
her, they cannot in any way interfere to prevent it. This 
woman, when unable any longer (in conseqnence of the se- 
verity of her disease) to follow her miserable calling, has no 
other resource (prostitution failing), to procure her a livelihood 
than to fall back on the foul wards of a workhouse (Acton).] 
cities like London, Manchester, Dublin, Sheffield, Preston, 
the severity of the cases is greater than in the protected 
[A protected district is one where a woman, instead of con- 
tinuing wholly or in part to gain an honest livelihood, walks 
the streets, soliciting different men, and consequently comes 
under cognizance of the police as being a common prosti- 



syphilis. 397 

tute. The British Legislature has determined that in cer- 
tain garrison towns such a woman, after being repeatedly 
warned, and still persisting in a life of prostitution, shall 
submit to a medical examination, on the ground that, should 
she be diseased, she would communicate a contagious com- 
plaint to those having relation with her. It is further enact- 
ed that if the woman be found diseased, she shall be at once 
sent to hospital, and not allowed to leave till she is, in the 
opinion of the surgeon, perfectly cured. If then desirous of 
abandoning her evil courses, the girl is relieved from further 
surveillance, and-willbe sent to her friends at the Govern- 
ment's expense. If, on the other hand, a common woman, 
on being discharged from hospital, and released altogether 
from the operation of the Acts, returns to a protected dis- 
trict, and is again found by the police acting as a public 
prostitute, she must again be registered. In every case the 
authorities wish it to be clearly understood that they do not 
sanction or authorize prostitution ; they only watch over it 
from their anxiety to prevent its worst evils, and to ameliorate 
the condition of the women, and check disease (Acton).] 
places, where the great majority (after the Acts have been 
in operation for a year or two) suffer from very mild forms 
of the disease. In 1870 a Royal Commission was appointed 
to consider the questions raised in the House of Commons 
on a motion for a repeal of the Act. The report of this 
Royal Commission speaks most decidedly upon the effects 
of the Acts in the reduction of the worst forms of disease 
among the lower classes of prostitutes, and acknowledges 
that they have both directly and indirectly promoted the ob- 
jects sought to be attained by those Acts. " They have 
purged the towns and encampments to which they have been 
applied of miserable creatures, who were masses of rottenness 
and vehicles of disease ; " and it was agreed that, for the pub- 
lic good, particular districts which are from any cause pecu- 
liarly liable to contagious disease should be subjected to 
special sanitary legislation, (e) In passing these Acts also, 
Parliament pronounced the strongest protest against the 
right of an individual suffering from a loathsome disease 
knowingly to communicate it to another ; hence, in the in- 
terest of all, the State has the right to limit the personal lib- 
erty of such persons as may be considered dangerous to the 
common welfare, and to use force, if necessary, to obtain an 
examination as to the condition of their health. Regular, 
frequent, and thorough examinations are absolutely neces- 



398 SYPHILIS. 

sary. [It seems useless to argue with the opponents of these 
Acts, who, while loudly denouncing them as immoral be- 
cause they render vice easier and safer to men, yet wish for 
the establishment by Government of voluntary lock hospi- 
tals and lock wards, which, if they proved equally efficient, 
must obviously be attended by the same result ; who, while 
stating that the Acts render vice easy and safe, declare al- 
most in the same breath that they are hygienically a failure, 
and that wherever they have been in operation disease has 
increased instead of diminished : who, while charging them 
with all sorts of pernicious and degrading influences, yet 
deny them any credit for the collateral benefits which they 
have been shown to have produced ; who denounce them as 
unwarrantably interfering with individual liberty, on account 
of their compulsory clauses, and yet would not object to the 
compulsory detention of women in hospital until cured, pro- 
vided they were left to apply voluntarily for admission. How, 
they further ask, if the present system is an infringement of 
personal liberty, is that principle less infringed if the compul- 
sion is removed from one end of the procedure but retained 
at the other ? Surely if compulsion is unjustifiable, it should 
be abolished altogether ; but if it is to be retained at all, it 
should be retained in the form which has been found most 
effectual ; and the evidence of those most competent to judge 
shows that the early detection of disease in public women by 
periodical examination is essential to the efficiency of the 
system. Even the Royal Commission were constrained to 
say, " We are satisfied from the evidence that the frequent 
examination of women is the most efficacious means of con- 
trolling the disease." It is not less important in the interest 
of the unfortunate women themselves, who' obtain the im- 
mense advantage that their disease is discovered and treated 
at the earliest possible period, so that while they are pre- 
vented communicating it to others, they are themselves saved 
from all the serious and painful consequences of neglect. 
(Brit. Med. Journ., July 22, 1876)]. (/.) The beneficial effect 
of these Acts on the civil population cannot be ignored. 
During the five years 1870-74 the annual death-rate from 
syphilis (including congenital syphilis) in the eleven districts or 
stations where the Acts were then in operation, was 21 per 
cent, lower than it was during the five years 1861-65 before 
the Acts came into operation in 1866 ; whereas in the rest 
of England and Wales the death-rate from this disease was 
20 per cent, higher in the second than in the earlier period. 



spphilis. 399 

(g.) Up to the present time, it has been everywhere found 
that just that class of prostitutes who are the most apt to 
spread syphilis will not subject themselves to treatment ex- 
cept under compulsion. All prostitutes found to be syphili- 
tic should be kept in hospital till they are cured. (/*.) It 
may also be fairly urged and acted upon, that entire classes 
of men who notoriously contribute largely to the spread of 
syphilis, as, for instance, soldiers and sailors, should be sub- 
ject to periodical examinations ; and that sailors especially 
should be inspected before leaving a port, and again before 
entering another, and that if found infected they should be 
placed in quarantine. The workmen in some of the glass- 
works in the neighborhood of Lyons have of their own ac- 
cord demanded such examinations, to do away with the pos- 
sibility of infection from the tubes used by them in blowing 
glass, which are passed from mouth to mouth (Baumler). (/.) 
Not only ought the Contagious Diseases Act to be main- 
tained and extended to the whole of this country, but the 
time has come when, as Dr. Baumler observes, it is the duty 
of all civilized states to combine and adopt some common 
course of action against these diseases. There is need of 
universal prophylactic regulations being more and more wide- 
ly recognized. 

A great responsibility rests upon those who oppose the 
working of such Acts — so fully proven to be preventive of 
disease, and in every respect beneficial. " In the eyes of 
every physician, and indeed in the eyes of most Continental 
writers who have adverted to the subject, no other feature 
of English life appears so infamous as the fact that an epi- 
demic which is one of the most dreadful now existing among 
mankind, which communicates itself from the guilty hus- 
band to the innocent wife, and even transmits its taint to 
the offspring, and which the experience of other nations con- 
clusively proves may be vastly diminished, should be suffered 
to rage unchecked because the legislature refuses to take of- 
ficial cognizance of its existence, or proper sanitary measures 
for its repression." (Lecky, History of Europ. Morals, Vol. 
II., p. 301). 

(2.) The facts relative to the Pathology of syphilis which 
have been stated in the text, show that Prophylaxis ought 
to take cognizance of the vehicles by which healthy persons 
are apt to be inadvertently infected — (a) From the use of 
such drinking vessels, plates, spoons, towels, &c, used by 
those suffering from secondary forms of syphilis ; (b.) con- 



400 SYPHILIS, 

tamination from surgical instruments which have been em- 
ployed upon the syphilitic ; (c.) the selection of healthy 
children from whom other children are to be vaccinated — ■ 
only those children known to be healthy, and whose parents 
are known to the physician, should be used as the sources of 
vaccine matter ; (a 7 .) the choice of wet nurses for healthy 
children ought also to be carefully selected, so as to exclude 
those who may show the least suspicion of having had sy- 
philis ; (e.) on the other hand, it is necessary to prevent 
children with hereditary syphilis being given to healthy wet 
nurses ; (/.) the guardians of syphilitic children ought to 
be warned of the danger of their infecting healthy children 
through kissing them, and also by the use of the eating and 
drinking utensils of such infected children (Baumler). 

(3.) Individual Prophylaxis — From what has been written, 
it must appear clear that the only chance of preventing in- 
fection, alike on the part of the male and the female, is per- 
sonal cleanliness after sexual intercourse. Much of the good 
that has resulted from inspection of females to the females 
themselves, as in Paris, Brussels, and other places, has been, 
I believe, mainly attributable to the greater attention to per- 
sonal cleanliness which such inspections have brought about. 
Numerous lotions have also been used ; and if a man will 
have sexual intercourse with a strange woman, let him wash 
immediately after the act, taking care to cleanse thoroughly 
the folds of the prepuce, especially near the fraenum, and in 
the sulcus of the corona glandis. If a woman will have sex- 
ual intercourse with a strange man, let her use a syringe with 
hot water, to wash out the vaginal passage, taking care to 
cleanse thoroughly the folds of the mucous membrane at the 
orifice of the canal and of the labia pudenda. The real pre- 
ventive remedy after exposure to infection is the most an- 
cient, the most simple, and the most efficient — Wash, and be 
clean. 

(4.) Syphilization. — By this name an operation is meant 
which has for its object the eradication of syphilis from the 
system by repeated inoculations of the syphilitic virus itself. 
Dr. Boeck, of Christiana, is the most persistent advocate of 
this mode of dealing with syphilitic cases as a remedy against 
constitutional affections. And it was at one time seriously 
proposed to introduce syphilization as a prophylactic, from 
its analogy to the inoculation of the virus of variola (Auzias 
Turenne). The method is entirely unjustifiable. 

{b.) Therapeutic treatment. — As in the case of other spe» 



SYPHILIS. 40I 

ific diseases that are implanted by inoculation, the effect of 
the virus begins at once at the point of inoculation, and may 
not be destroyed as to its contaminating powers by any 
agency we know of. Experience shows that we must not 
conclude that, even by an early destruction of the sore, the 
occurrence of constitutional infection will be prevented ; 
and the application of caustics to abraded surfaces after their 
exposure to contagion is quite useless to prevent infection. 
The poison is observed in a very short time — within a few 
hours (Berkeley Hill). Still, however, in some cases positive 
results have been obtained which encourage attempts to 
arrest the local progress of the sores with escharotics, if they 
are applied at an early period, and before contamination of 
the system is evinced by indurations. Ricord and Sigmund 
have found that sores destroyed by the more powerful caus- 
tics, within from three to five days, have not been followed 
by syphilitic symptoms. But these may have been cases of 
soft chancre, which would not infect. The only efficient 
caustics for this purpose are — (1.) The strong nitric acid ; 
or, (2.) The potassa cum calce (most conveniently used in 
the form of small sticks). Nitrate of silver is useless, from 
its limited action and deficiency of penetration. 

If the sore threatens to slough, the parts should be wiped 
dry, and fusing nitric acid applied, and afterwards a lotion 
of the potassio-tartrate of iron, while the same drug is given 
internally. Chloride of zinc paste (Fell's) is a useful eschar- 
otic to excite a healthy action round the periphery of a sore. 
If great pain attends the local progress of the chancre, mor- 
phia in liquor ammonia acetatis is highly beneficial. " Black 
wash " of the strength of 8 grains of calomel to the fluid 
ounce of lime water, or weaker, as 5 or even 3 grains to the 
ounce, is of use in the treatment of large ulcerating indura- 
tions. The experience of 300 years has shown that mercury 
is a remedy which acts as a direct antagonist to the virus of 
syphilis ; and no unprejudiced person can deny that its ac- 
tion upon syphilis is quite evident, especially upon the cuta- 
neous manifestations of the disease. Mercury, administered 
during a primary sore, seems to be one of those agents which 
are able to break the regular order of the manifestation of 
symptoms, as it does to several other diseases ; although it 
may not seem to possess any certain prophylactic power. 
[There are remarkable variations in opinion as to the influ- 
ence of mercury in curing syphilis. At one time discussion 
ran high regarding its use ; and, of course, extreme state- 
36 



402 SYPHILIS. 

ment's were made on both sides, while the facts adduced 
never warranted the extreme conclusions. Consequently, at 
one time mercury has been regarded as capable of absolutely 
preventing the constitutional affection ; at another time it 
has been accused of giving to the syphilitic virus the impulse 
which sets up its worst results. It is now quite certain, how- 
ever, that mercury administered continuously to the extent 
of salivation, or approaching it, exerts a poisonous influence, 
and produces constitutional effects of a very dangerous kind 
(Graves) ; and Hunter himself says " new diseases arise from 
mercury alone ;" while it cannot be doubted that in cases in 
which mercury has been freely given, we are never certain 
that secondary symptoms may not supervene. Barensprung, 
of Berlin, during his' most extensive experience, came to the 
conclusion that syphilis not only can be cured without mer- 
cury, but, under its use, he believed the disease is often ren- 
dered latent for. months and years, and its complete cure de- 
layed. Starvation and Zitmann's weaker decoction were the 
means he employed for cure (Ann. de Berlin Charite, ix., i, 
i860 ; Syden. Society Year-Book, 1861). Hermann came to 
similar conclusions, from his experience in the syphilitic 
wards of the Vienna Infirmary. The experience of Diday 
is not less decided. He states that mercury cannot now be 
said to cure syphilis radically, so as to render all relapse im- 
possible. He does not, however, as is the case with the 
others, practically withhold mercury in every case. If the 
primary lesion becomes an indurated, woody chancre, mercury 
is given. If the chancre is a doubtful one, he recommends 
waiting till some of the early constitutional phenomena ren- 
der the nature of the case evident, and indicate the probable 
gravity of the syphilis with which he has to deal. He em- 
ploys iodine, iron, and quinine, on the appearance of slight 
relapses, with a tonic and supporting regimen. He recom- 
mends iodides, to combat the chloro-anaemia, and to relieve 
the pain of tertiary ulcerations. 

Numerous examples may be seen in museums, which are 
placed there to show that the poisonous effects of mercury 
produce worse lesions than those of syphilis ; and, when 
combined with the syphilitic virus in a strumous person, the 
worst lesions of all. In the extreme of syphilitic infection, 
it ought never to be forgotten that a specific chlorosis results 
from syphilis, amounting to anaemia ; and that mercury will 
bring about a similar anaemia. But while numerous instances 
ft,re quoted by authors of the poisonous effects of mercury 



SYPHILIS. 403 

inducing lesions similar to those of syphilis, the investiga- 
tions of Kussmaul, Professor of Medicine at Erlangen, show 
that mercurial poison produces no single affection or symp- 
tom that is identical with, or not easily distinguishable from, 
those of syphilis. His experience was among the manufac- 
turers of mirrors using mercury in the town of Furth ; and 
he shows that mercury has but one influence over syphilis — 
that is, the power of controlling many of its symptoms. 

Both kinds of treatment (mercurial and non-mercurial) 
have been extensively tried since 1816, and formal experi- 
ments have been organized on the subject, namely, — First, 
In 1822, in Sweden, by Royal command, when reports were 
annually furnished from civil and military hospitals as to 
trials of the two methods ; Second, Dr. Fricke experimented 
in the Hamburg General Hospital, and published his results 
in 1828 ; Third, In 1833 the French Council of Health pub- 
lished a report on the subject. Long before any of these 
reports were initiated, however, the surgeons of the British 
Army had the boldness to declare themselves against the 
system of treatment with mercury, as it was then carried out, 
and, running into the opposite extreme, introduced measures 
of non-mercurial treatment altogether. This change was 
mainly due — (1.) To Mr. Fergusson, who practised it during 
the Peninsular Wars (Med.-Chir. Trans., Vol. IV.) ; (2.) To 
Mr. Rose, of the Coldstream Guards, at the same time, but 
independently of Mr. Fergusson ; (3.) To Dr. John Thom- 
son, the first Professor of Military Surgery ; who, by lec- 
tures in the University and College of Surgeons in Edin- 
burgh, and by his published writings, was mainly influential 
in convincing Scotch medical men of the evil effects of mer- 
cuey in venereal diseases. The inquiry, begun in 1816 by 
these military surgeons, requires to be re-investigated with 
all the present advanced knowledge of the nature of the di- 
sease which we now possess, and with a better prospect of 
detecting the fallacies which surround the investigations. Un- 
der the simple treatment of those eminent men, there can be 
no doubt that mixed cases of soft, as well as of indurated 
chancres, and specific or syphilitic sores, were allowed spon- 
taneously, as it were, to develop their distinctive characters. 
No confidence can now be placed in the results thus pub- 
lished, as derived from clinical observation, because the cure 
of soft, suppurating, and mixed sores, gonorrhoea, vegeta- 
tions, suppurating bubos, are all indiscriminately given as 
evidence of the cure of syphilis. Moreover, cases cannot 



404 SYPHILIS. 

be accepted as cured at the time they are simply discharged 
from present treatment, because they may seem to be pro- 
gressing to a favorable termination, but not absolutely cured, 
as is the case with the records of Fricke's experiments. 

The great benefit obtained by the experiments, observa- 
tions and discussions regarding mercury in syphilis, carried 
on during the first quarter of the present century, as Dr. 
Berkeley Hill justly observes, has been to show — (1.) That 
all venereal ulcers can be healed without mercury ; (2.) That 
this drug is not the cause of the relapses so frequent in syph- 
ilis ; and, (3.) That very much less mercury is required to 
control syphilis than had been previously supposed neces- 
sary. Some interesting cases of syphilis cured without the 
use of mercury are related by Surgeon-Major Dr. Peter Boi- 
leau, in the Brit. Med. Journ., for July. 1879.] 

The present position of opinion with regard to mercury in 
the cure of venereal sores seems to be this, namely, — That 
it is a very valuable and essential remedy in cases of syphilis, 
but not in cases of soft chancre ; and the difficulty is to ex- 
press always the nature of the cases for which it is most 
suitable. Even those who believe most fully in its virtues 
acknowledge that in primary affections, as when given in the 
treatment of the local sore, its administration will not always 
prevent the occurrence of constitutional symptoms; never- 
theless the value of mercury in the cure of the induration of 
the true infecting chancre is now fully recognized. The 
local lesion, if it appears after the usual prolonged period of 
incubation, is as much a manifestation that the constitution 
is already affected as is the developed vesicle of variola 
vaccina a manifestation that the constitution is affected with 
variolous poison. Looking, also, to the nature of the virus 
of syphilis, the excision of the primary lump or sore — the 
specific induration — as practiced by Dr. Veale, assistant to 
the Professor of Medicine in the Army Medical School at 
Netley (Edinburgh Monthly Journal, July; 1864), and by 
Dr. Humphrey, of Cambridge, {British Medical Journal, 
August 13, 1864), is a justifiable operation; for the original 
sore, when it has become a "lump" (as in its state of 
" woody-like " induration), is an undoubted maintainer of 
infection and of contamination of the system. If, therefore, 
it can be easily and completely insulated, as when on the 
prepuce, the cure of the constitutional symptoms may be 
facilitated and shortened. There are also certain forms of 
secondary syphilis for which the administration of mercury 



SYPHILIS. 405 

is unsuitable. These are the pustular eruptions, or ecthy- 
matous states in rupia and in syphilitic anaemia. For the 
cure of other secondary symptoms mercury is certainly of 
service. If given to the extent to which I have limited its 
use in the text, I believe that secondary symptoms disappear 
more rapidly under its regulated use than by any other plan 
of treatment. All our treatment of syphilis rests on that evi- 
dence which must always guide the hand of the physician, 
namely, — practical experience. That has certainly taught 
us that the mercurialism of John Hunter's time was an error; 
and that its regulated administration in cases of syphilis is 
undoubtedly beneficial, and especially during the evolution 
of the specific symptoms of infection. Dr. Jeffrey Marston, 
late of the Royal Artillery, has given an admirable summary 
{British Medical Journal of Feb. 21, 1863) of the means and 
indications of treatment by mercury which he has found 
most useful. His experience shows that the system ought to 
be affected as slowly as possible; and there ought to be a re- 
mission of the remedy for a time as soon as that effect has 
been attained. As soon as the symptoms for which the 
mercury was given have disappeared, steel and other mineral 
tonic remedies ought to be given; and in three cases where 
the general health seemed to have suffered, podophyllin in 
small doses (one-sixth of a grain), with extract of belladonna, 
was given with marked benefit. If the system is too early 
brought under the influence of mercury, and the symptoms 
are not benefited, chlorate of potash in compound tincture 
of cinchona may be given with advantage; and in strumous 
subjects the bichloride of mercury, dissolved in ether and 
added to cod-liver oil, is found to be most useful. Some of 
the most intractable forms of syphilitic squama are best 
treated by a combination of liquor arsenicalis, solution of 
bichloride of mercury in very small doses, and tincture of 
sesquichloride of iron; while the use of soap in ablution 
ought to be avoided (Startin). In the administration of 
mercury for the cure of syphilis, salivation, or anything ap- 
proaching to that condition, should never be induced. Ten- 
derness of the gums should be the utmost physiological 
effect, very gradually and gently brought about. As soon as 
the evolution of consitutional symptoms has commenced, 
such as the specific induration of the sore or glands, cutan- 
eous, scaly, tubercular, condylomatous affection, or iritis, 
the sooner mercurial treatment (to the extent indicated) is 
commenced the greater will be the benefit. The good 



406 SYPHILIS. 

effects of mercury are known by the following results : — 
" Given early, it promotes the dispersion of the induration 
at the point of contagion or inoculation, and the enlarge- 
ment of the glands; it delays and lessens the severity of the 
cutaneous eruptions, and of all the symptoms which accom- 
pany the early skin eruptions " (Berkeley Hill). When in- 
duration is apparent, mercury ought to be at once adminis- 
tered; and all the useful effects of the remedy are generally 
obtained when the slightest possible sign of its influence is 
betrayed by the gums and breath. The most convenient 
form of administration is either a pill or fluid solution of 
corrosive sublimate (perchloride). The dose should always 
be small, and combined so as not to irritate the bowels. 
Grey powder or blue pill may be compounded in the follow- 
ing forms, namely : — Two grains of grey powder with two 
grains of compound ipecacuanha powder, made into a pill 
with glycerine, two of which are to be taken daily; or two or 
three grains of blue pill combined with a quarter of a grain 
of opium powder, with sufficient glycerine to make a pill, and 
taken every night at bedtime. Either of these forms is suffi- 
cient for women and young men. In adult men, three grains 
of blue pill or grey powder twice or thrice a day; or one 
grain of calomel every night and morning, with a third of a 
grain of opium, are most suitable. When the mercury is 
obviously producing its physiological results, it may be 
omitted for a day, and then again carried on in smaller or 
less often repeated doses. Dr. Berkeley Hill recommends that 
the perchloride of mercury be mixed with iodide of potass, so 
that a freshly formed biniodide of mercury is kept suspended 
in a solution of iodide of potass, in the following formula : — 

1)6 Perchloride of Mercury, gr. 3; Iodide of Potass., grs. 
96; Compound Tincture of Bark, 4 ounces; Sesquicarbonate 
of Ammonia, grs. 60. Water sufficient to make up 8 ounces. 

The dose of this compound ought to be two teaspoonfuls, 
half an hour before meals, three times a day. Two-thirds of 
a grain of perchloride of mercury may be taken daily; but 
except in such a solution as the above its action is uncertain. 
In Germany, Zitmann's decoction is much used. It is of 
two kinds — the stronger and the weaker. The former is 
compounded as follows : — 

^ Rad. Sarsaparillse, J xii. ; Aquae, Ibxxiv. ; Coque per 
horas duas et adde Aluminis, § iss.; Hydrarg. Chloridi, mitis 
(calomel), Iss.; Antimonii Oxy. sulphureti, 3i.; misce. 
Coque ad f, et adde Fol. Sennse, § iii. ; Rad. Glycyrrhizae, 



SYPHILIS. 407 

§iss.; Sem. Anisi, § ss. Infunde per horam et cola. The 

dose of this decoction is half a pint to a pint morning and 

evening. 

The weaker decoction is compounded as follows : — 
Capiat residuum decocti fortioris et adde Radicis Sarsa- 

parillse, 3 ii.; Aquas, lbxxiv. ; Coque per horas duas et adde 

Cort. Canellae, Cort. Limonem, Sem. Cardamomi, a a 3 in. 

Infunde per horam et cola. The dose of this decoction is 

one pint at intervals during the day. 

Another mode of preparing it with somewhat different 

proportions of ingredients is given by Dr. Berkeley Hill, as 

follows : — 

I£ . Sarsaparilla, § xii. ; Water, three gallons. Macerate 
twenty-four hours, and put in a linen bag ; White Sugar, 
3 vi.-; Alum, 3 vi. ; Calomel, 3 iv. ; prepared Cinnabar, 3 i. 

Hang the linen bag in the liquor and boil down, while add- 
ing four gallons more water, till the liquor is reduced to 
two gallons ; remove the bag, and add to the decoction the 
following ingredients, namely : — Anise Seeds, 3 iv. ; Fennel 
Seeds, 3 iv. ; Senna Leaves, § i)4 ; Liquorice Root, | iss. 
Press and strain. 

About half a pint to a pint is the daily quantity to be con- 
sumed of the compound. While the amount of mercury it 
contains is rarely enough to produce any unpleasant effects, 
it is enough to control the disease. A weaker decoction of 
the woods is free from mercury, but is of no value beyond a 
diet drink. 

Iodide of potassium, in doses adjusted to the individual 
case, appears to act with rapid benefit in some of the syphil- 
itic diseases of the interior of the cranium giving rise to ex- 
treme pain. Its administration often causes intense suffer- 
ing in patients who have been treated previously by mercuri- 
als. Two distinct effects are produced : — First, the com- 
pounds of mercury fixed in the body are rendered soluble 
and active ; and secondly a form is given to them which al- 
lows of their elimination, with more or less rapidity, in a state 
of combination with one of the elements of the iodide ; and 
thus the patient is subjected anew to a mercurial treatment 
by the compounds of mercury already present in his body 
(Melsens, in Brit, and For. Med.-Chir. Review, 1853). The 
dose of iodide of potassium should at first be small, not more 
than fifteen grains in the twenty-four hours — increasing the 
dose if the patient bears it well (Melsens, Guillot). Its ac- 



4°8 SYPHILIS. 

tion is aided by a blister over some portion of the shaven 
scalp, and by having the blistered surface dressed with mer- 
curial ointment ; and generally, it may be said that local 
treatment gives very valuable aid. For example, cutaneous 
or mucous raised papules remaining persistent, an ointment 
composed of oxide of zinc, calomel, and simple cerate, has- 
tens their absorption. Eruptions of lichen, acne, and herpes 
are similarly benefitted by the application of oxide of zinc 
lotion or ointment ; and if prurigo and urticaria be also pres- 
ent, diacetate of lead lotion will expedite the cure. Vesiculo- 
crustaceous spots will cease to reappear if the affected parts are 
painted for a few days with a solution of nitrate of silver (gr. 
x.-xx. to § i), and oxide of zinc lotion applied afterwards. 

In the more advanced stages of the suppurative affec- 
tions, the use of pyogenic counter-irritants ought not 
to be neglected, such as tartar-emetic ointment. They 
tend to keep up just so much of a discharge as may be 
consistent with the strength of the patient ; and are worthv 
of a trial. 

In the dry forms of syphilitic cutaneous diseases, and in 
chronic eczema of the extremities, tar ointment,or an alcoholic 
solution of tar, is an excellent application ; and the disap- 
pearance of indolent glandular swellings is greatly aided by 
the use of strong solutions of iodine. Superficial forms of 
ulceration attending the pustules of ecthyma are benefitted 
by the use of solutions of nitrate of silver or sulphate of cop- 
per, and generally by caustics and local stimulants. If a 
sloughing condition threaten ulcerating sores, lotions of the 
potassio-tartrate of iron will generally improve their aspect. 
In psoriasis palmaris, and similarly fissured conditions of the 
skin, glycerine lotions are most useful. But all these local 
remedies, it must be remembered, are only aids to the con- 
stitutional treatment, whether by mercury or iodide of potas- 
sium, or simply by a well-regulated hygiene. The patient, 
during the whole of the treatment, should be warmly clad — 
should be fed upon a good but plain diet — should take plenty 
of exercise in the open air in fine weather — should use occa- 
sionally (once or twice a week) — warm baths — and avoid 
stimulants, unless specially indicated and prescribed. Dur- 
ing the febrile stage and the exanthem stage he ought to be 
confined to his bed. 

The administration of mercury, to affect the system rap- 
idly, is best effected through the agency of the mercurial 
vapor bath. It is a mode of administration not liable to af- 



SYPHILIS- 



409 



feet the digestion, and it permits other remedies to be given 
by the mouth at the same time, if they be considered neces- 
sary. It is also mild, slow, and equable in its action. The 
mercurial vapor bath is to be managed in either of the fol- 
lowing ways. The first method is best adapted for the prac- 
tice of a large institution ; the method recommended by Mr. 
Lee is better suited for private practice : — 

" The patient is seated on a chair, and covered with an 
oil-cloth lined with flannel, which is supported by a proper 
framework. Under the chair are placed a copper bath, con- 
taining water, and a metallic plate, on which is placed from 
one to three drachms of the bisulphuret of mercury, or the 
same quantity of the grey oxide, or the binoxide of this met- 
al. From five to thirty grains of the iodide of mercury may 
be employed, or a scruple of the iodide, with a drachm and 
a half of the bisulphuret. Under the bath and plate spirit- 
lamps are lighted. The patient is thus exposed to the influ- 
ence of three agents, — heated air, steam, and the vapor of 
mercury. At the end of five to ten minutes perspiration 
commences, which becomes excessive in ten or fifteen min- 
utes longer. The lamps are noAv to be extinguished ; and 
when the patient has become moderately cool, he is to be 
rubbed dry. He should then drink a cup of warm decoction 
of guaiacum or sarsaparilla, and repose for a short time " 
(Langston Parker). 

Mr. Henry Lee's mode of proceeding is more simple : — 
" A special and convenient apparatus is used (made by Sav- 
igny & Co.), which consists of a kind of tin case, containing 
a spirit-lamp. In the centre, over the flame, is a small tin 
plate, upon which from fifteen to thirty grains of calomel is 
placed, while around this is a sort of saucer, filled with boil- 
ing water. The lamp having been lighted, the apparatus is 
placed under a common cane-bottomed chair, upon which 
the patient sits. He is then enveloped, chair and all, in one 
or more double blankets, and so he remains well covered up, 
for about twenty minutes, when the water and mercury will 
be found to have disappeared." 

With regard to sarsaparilla as a remedy, Sigmund, Syme, 
and many other acute observers, have come to the conclusion 
after long and careful trials of the best sarsaparilla, that it 
does not, per se, exercise the slightest perceptible influence 
on the course and termination of syphilitic diseases. It is 
usually given in combination with some mercurial prepara- 
tion, as in the decoction of Zitmann. 



4IO TABES DORSALIS TETANUS. 

As to the original local sore of syphilis, it may be dressed 
simply with lint soaked in warm or cold water, and renewed 
every three or four hours. The indurated glands, if they 
are painful, may be fomented, and the horizontal posture 
maintained. Moderate exercise may be taken if all local 
irritation is subdued ; and then slightly stimulating lotions 
may be used to the sore, such as sulphate of zinc, in the pro- 
portion of one or two grains to the ounce ; or the liquor 
plumbi diacet. dil. of the pharmacopoeia ; or the black or yel- 
low wash if the surface is indolent. 

Talbes DorsallS. — {See Locomotor Ataxv, Progressive). 

Tetanus — Definition. — -Involuntary, persistent, intense, 
and painful contractions, cramps or spasms, of more or less 
extensive groups of voluntary muscles ; so that the whole of 
the body may seem to be affected, the spasm yielding and 
becoming intermittent in some groups of muscles, while at 
the same time it exists in others, or the continuous tonic 
spasms are characterized by paroxysmal aggravation of 
extreme intensity. 

Treatment. — So long as the phenomena are peripheral and 
reflex, the removal of the offending part may arrest the dis- 
ease ; but when it has become central, it is probably always 
fatal. There are thus two forms of tetanus which demand 
recognition for treatment as early as possible. Baron 
Larrey affirms that this disease, if left to nature, is 
quickly fatal. Sir James Macgrigor says that all the most 
powerful remedies were fully tried in the Peninsular War, 
and that little or no dependence could be placed on any of 
them. There is great tolerance of all kinds of sedatives and 
narcotics. 

Much good, however, is gained by attempting to restore 
the secretions to a healthy state ; also by supporting the 
patient with food and drink, and by endeavoring to tranquil- 
lize the high irritation under which he is laboring. The 
medicines to be employed are moderate doses of purgative 
medicines, with tinct opii m xxv., or its equivalent, 10 grains 
of Dover's powder, given every three or four hours ; and 
these conjoined with moderate quantities of wine, sago, mixed 
with strong beef-tea or soup, or other nutritious diet. Musk,, 
also, in ten-grain doses, has been given with some advantage. 
Some authors lay much stress on a local treatment in trau- 
matic tetanus. Baron Larrey, as the result of his great ex- 



TETANUS. 411 

perience, says : " When it is caused by the wound, we should 
not hesitate to operate on the first symptom of tetanus, and 
thus, as far as possible, remove the causes of irritation." If 
tetanus follows amputation, he recommends the stump to be 
sprinkled with powdered cantharides ; and in cases where a 
nerve has been included in the ligature, that the ligature be 
removed either by section or by actual cautery. In the 
British army, however, all these proceedings have been 
adopted, and with very little success. Amputation has been 
frequently performed without any mitigation of the symptoms. 
The wound has also been excised, submitted to actual cau- 
tery, been blistered, and dressed with every kind of ointment; 
but the disease has run its course^ cither uninfluenced, or its 
fatal termination has been accelerated. Hennen has even 
seen the wound heal and the patient die on the same day. 
Nothing, in fact, is so r.nsatisfactory as the results yet ob- 
tained from either the general or local treatment of this fatal 
affection. Larrey has often attempted, from the difficulty of 
swallowing fluids that sometimes attends tetanus, to pass an 
elastic tube ; but in all cases he says he met with a contracted 
state of the oesophagus impossible to overcome, while the 
attempt was constantly followed by the immediate occurrence 
of the severest spasmodic attacks. 

" If, however," as Mr. Poland observes, " we can help our 
patient on one day after another, we gain much. Constant 
watching and constant attention are required by night as 
well as by day, and unflinching perseverance on the part of 
the sufferer to aid all efforts made in his behalf, besides the 
avoidance of all causes of excitement, and more especially 
drafts of cold air or winds, taking care to preserve a uniform 
temperature as much as possible." No hope of recovery 
may be indulged in unless the spasmodic seizures continue 
to diminish in length and frequence, distinct relaxation of 
the contracted muscles occurring during those intervals of 
diminished spasm ; and unless the patient becomes able to 
take food, recovery in the fortunate cases takes place with 
extreme slowness. It is not till after the lapse of weeks 
that the muscles entirely lose their spasmodic tension. 
Russian vapor baths are well spoken of by Hasse and 
Niemeyer. 

Too free use, alike of narcotics and of anaesthetics, must 
be guarded against. They are valuable aids in maintaining 
the existence of the patient from paroxysm to paroxysm. 
Aconite has been used in large and repeated doses by De 



412 TETANUS. 

Morgan, Smith, Sedgwick, Woakes, and Wunderlich. It 
ought to be used hypodermically, and there appears to be a 
great tolerance of the remedy. Cannabis sativa or Indian 
hemp, is a remedy of real value, if it can be got genuine and 
fresh. Three grains of the extract, or thirty drops of the 
tincture, may be given every half hour or hour till narcotism 
is attained. Cold should at the same time be applied to the 
spine (Muller, O'Shaughnessy, Chuckerbutty). 

The more or less obstinate constipation of the bowels 
which characterizes this disease, and which is accompanied 
by a foetid state of the dejections, ought to be overcome by 
(i.) turpentine enemata, and (2.) calomel and jalap purga- 
tives. This is most important. 

A case of traumatic tetanus under the care of my friend, 
Dr. John Liston Paul, Surgeon-Major of H. M. Indian 
service, is reported in the Madras Monthly Journal of Med- 
ical Science for July, 1872, which recovered under the per- 
sistent use of belladonna tincture, carefully observing the 
effects of the drug upon the system. The bowels were first 
freely acted upon by calomel, gr. v., and compound jalap 
powder, gr. xx. ; and immediately on the action of the bowels 
commencing, ten minims of the tincture of belladonna were 
given in half an ounce of water. In an hour five minims 
more were given ; and every hour afterwards an increase of 
three minims was added to the previous dose, till twenty 
minims were given at one dose. The administration of 
belladonna was commenced at 10:30 a. m., and by 4:30 p. m. 
a dose of twenty minims was thus gradually reached. This 
dose was continued in half an ounce of water every hour till 
10 p. m., after which it was given every second hour till the 
following day, when no relief to the rigidity or paroxysms 
being obtained, this dose was increased to twenty-five minims 
every hour. This treatment was persevered in, with the aid 
also of chloral hydrate occasionally, as well as ice applied to 
head and spine, and movement of the bowels by active pur- 
gatives of jalap and croton oil. At three intervals the bella- 
donna had to be suspended, on account of its poisonous 
physiological action being obvious in the delirium, thirst, 
and other symptoms. The patient was under active treat- 
ment with belladonna for fifteen days ; the amount of tinc- 
ture taken in that time being ten ounces four drachms and 
thirty minims. 

Yandell states that chloroform up to this time has yielded 
the largest percentage of cures in acute tetanus {Brain, Oct., 



TETANUS. 413 

1878). He- is of opinion that the true test of a remedy for 
tetanus is its influence on the history of the disease in the 
following respects : (a.) Does it cure cases in which the dis- 
ease occurred prior to the ninth day after the injury ? (b) 
Does it fail in cases whose duration exceeds fourteen days ? 
Tried by these tests he asserts that no agent has yet estab- 
lished its claims as a true remedy for tetanus. But among 
the numerous medicines used in the treatment of tetanus 
chloral is one of the latest, and appears to possess many 
advantages. Bauer, in his article on tetanus in Von Ziem- 
sen's Cyclopaedia, states that other remedies are practically 
and properly being more and more supplanted by chloral- 
hydrate. This is superior to every other means, even the 
inhalation of chloroform ; and the control of the spasm will 
be attained most satisfactorily by the combination of chloral 
with bromide of potassium. Billroth also records success in 
cases of tetanus from the use of chloral. 

Dr. J. R. Beck has collected (St. Louis Medical and Surgical 
Journal, June, 1872) thirty-six cases of traumatic tetanus 
treated essentially by chloral in which a recovery took place 
in twenty-one instances. Dr. H. C. Wood has tabulated 
(Treatise on Therapeutics, pp. 292, 293) eighteen additional 
cases resulting in nine recoveries and nine deaths. In the 
Practitioner for November, 1872, Dr. Macnamara, of Calcut- 
ta, gives his experience in tetanus among the natives, and 
says that he treats them by giving forty grains of chloral at 
bedtime, and by providing proper diet of a nourishing kind. 
In severe cases, an additional thirty-grain dose is given at 
midday. Out of twenty successive cases seventeen recov- 
ered. Though these cases were probably idiopathic in many 
instances, the testimony is nevertheless valuable. AVithin 
the past few years the medical journals have been constantly 
reporting cases of recovery from tetanus under the use of 
chloral, but isolated cases have their value diminished, be- 
cause the fatal cases are not so likely to appear in print. 
Nevertheless, the fact remains that many cases of traumatic 
tetanus have recovered while such treatment has been em- 
ployed. The drug has been introduced into the system by 
various channels ; M. Ore has treated cases of tetanus, 
though unsuccessfully, intravenous injections of hydrate of 
chloral {Practitioner, August, 1877); while success has fol- 
lowed its administration hypodermically in acute traumatic 
teta.n\is(American Journ. of Med. Sciences, April. 1877, p. 554), 
and it is stated that a case recovered where chloral, in con- 



414 TETANUS. 

junction with bromide of potassium, was given by enema 
{Hospital Gazette, New York, April, 1877, p. 15, from Lon- 
don Lancet). Dr. Agelastos, of Bucharest, believes that he 
prevents the occurrence of lock-jaw in traumatic cases by 
the timely employ of chloral {New York. Med. Journ., April, 
1877, p. 436). Verneuil says that chloral allays the muscular 
contractions, and especially those of the respiratory appa- 
ratus, which in the last stages of the disease cause asphyxia; 
and that it changes the acute into the chronic form of the 
disease. He gives instances of cure where the patients took 
100 grains and 245 daily without any bad symptoms. The 
first of these tetanic patients recovered after thirty days, 
having been given § vj. of chloral during that space of time 
{New York Med. Journ., 1876, p. 97). While in charge, as 
Resident Surgeon, of Dr. R. J. Levis's ward in the Pennsyl- 
vania Hospital, Dr. Roberts had the care of four cases of 
traumatic tetanus, all of which were treated with hydrate of 
chloral ; of this number three recovered, and one died out 
of nineteen cases. 

The evidence appears, indeed, to be very strong in support 
of the efficacy of chloral hydrate in the treatment of tetanus; 
and if one thing stands more prominently out in the history 
of medicine during recent years, it is the influence for good 
which is being exercised and becoming more easily controll- 
ed by the judicious use of those very powerful remedies. 
Dr. Van Somerer. of Madras also records successful cases 
from the use of chloral hydrate, and recommends a more 
heroic administration of the drug {Madras Monthly Journal, 
May 1872). 

Woorara or Curare is reported to have cured thirteen out 
of thirty-three cases (Demme, Busch). Appropriately given 
it effectually controls the spasms, and thereby spares exhaus- 
tion from them. The hypodermic injection of a solution of 
curare deserves extensive trial, commencing with such small 
doses as -J to \. of a grain, gradually increasing from \ to ii 
grains. A solution of one to two grains in 100 drops of 
water should be made fresh, and 10 drops of this solution in- 
jected as a dose. The action lasts about four or five hours, 
and upon this fact its repetition must be regulated (Dem- 
me). 

The Calabar bean seems next or equal in importance as a 
remedy in tetanus. In 1874 an analysis of published cases 
showed that out of 64 cases of traumatic tetanus treated by 
this medicine, 33 recovered. Since then this unusual pro- 



TETANUS. 415 

portion of cures of a disease which was before nearly always 
fatal, has been considerably increased. When the treatment 
has failed, the failure has been mainly attributable to an 
inefficient use of the remedy. The minimum dose of the 
extract of physostigma which should first be administered, 
is one-third of a grain. It should be repeated every quarter 
of an hour, until its specific operation is developed, and the 
spasms are completely overcome. This effect should be 
steadily maintained, and then reproduced as often as the 
spasms recur. It is usually necessary to increase the dose in 
order to maintain its original impression (Stille and Maisch, 
The National Dispensatory ', p. 1080), In the New York 
Medical Record of July 6, 1878, Dr. Burke reports two cases 
which occurred under his care in New York. One was seen 
on the tenth day after injury to the foot from treading on a 
rusty nail. Drop doses of fluid extract of physostigma, of a 
strength of 60 grains to the drachm, were first ordered, 
together with castor-oil, as the breath was foul. On the 
following day the dose of Calabar bean was increased to a 
drop every half hour combined with 3 i. of whiskey to coun- 
teract the depressing effects of the Calabar bean. Finally, 
the dose was gradually raised till mxiii. of the fluid extract 
of Calabar bean were administered every half hour; whilst 
as much as two pints of whiskey were given daily. The 
other ingesta were always fluid, consisting of milk, eggs, and 
beef-tea. As good effects were produced the quantity of the 
extract was gradually reduced, and finally, in about six 
weeks, entirely discontinued, good care and nourishment 
completing the cure. In a second case the dose was gradu- 
ally raised till mxv. of the fluid extract were given every 
hour, whiskey, at the same time, being always administered. 
The full physiological action of the drug was also obtainable 
by injecting hypodermically mxxii. to mxxxiii. of the alcoho- 
lic extract of the Calabar bean every hour, 3 iv. of whiskey 
were also given by hypodermic injection, and about an ounce 
by the mouth. The patient steadily improved under a treat- 
ment in which the alcoholic extract was injected hypodermi- 
cally in doses ranging from mx. to mxxv. every hour. He 
was ultimately discharged cured. One grain of the extract 
of Calabar bean may be given by the stomach; or one-third 
of a grain, mixed with x. or xv. minims of water,and neutra- 
lized by Carbonate of soda, by subcutaneous injection, re- 
peated in two hours, and increasing the dose gradually. 
Sir Joseph Fayrer records two cases of traumatic tetanus 



416 TETANUS. 

treated and cured by opium smoking and internal adminis- 
tration of chloroform and hemp. Both patients were Hindoos. 
The average quantity of opium-goolic smoked daily by one 
patient was 84 grains. The chloroform and hemp were given 
as in the following prescription: — 

t> Chloroform; mx ; Extract of Indian nemp, gr i. ; Mucil- 
age, 3 i; Camohor Mixt. z i. Misce. To be repeated every 
six hours. 

Surgeon-General Gordon, during the siege of Paris, 
reports that M. Demarquay saved several patients' lives who 
had manifested early symptoms in the form of trismus by 
means of very hot air-baths followed up by the hypodermic 
injection of morphine. In the fully developed cases these 
remedies were not successful. The inhalation of the nitrite 
of amyl has been recommended by Dr. W. S. Forbes of Phil- 
adelphia, in quantities of three to five drops. 

A case of tetanus having occurred, the bowels should first 
be relieved by a large enema with turpentine, after which 
perfect quietness in a darkened room, free from noise or cur- 
rents of air, must be insisted upon, as the best means of pre- 
venting the fits of spasms. The use of the ice-bag along the 
spine as recommended by Todd, has afforded relief by allay- 
ing spinal irritation; but its action is very depressing, By 
far the largest mass of testimony has accumulated in favor 
of supporting the strength of the patient by the frequent ad- 
ministration of nutritious foods, tonics, stimulants, and opi- 
ates, the latter of which must be given in the most liberal 
and persevering manner. These remedies (nutrient and 
medicinal) must be administered both by the mouth, by the 
rectum, and by the hypodermic method (Hamilton). Stimu- 
lants and abundant nourishment appear to give more pros- 
pects of success in the treatment of tetanus than any other 
means; and with the use of chloroform, chloral, and Calabar 
bean to lessen the spasms, perfect rest, quietness, and free- 
dom from currents ofair,the sufferer may be able to withstand 
the exhaustion, and live through the acute period of the 
disease. 

Systematic feeding of patients with liquid and strengthen- 
ing food, at short intervals, has been employed with very 
good results in the hospital of the University at Pennyslvania. 
The food must be given at intervals of every two or three 
hours; and should consist mainly of milk, with a small quan- 
tity of alcohol. Solid food is to be avoided. Medicinally, 
the patient must be brought well under the influence of the 



TETANUS. 41)- 

Bromide of Potassium, by an initial dose of two drachms to 
half an ounce, to be followed by half a drachm to a drachm 
every three or four hours. Thirty grains of chloral are to 
be given with some opium at bedtime. Chloral also is to be 
used when necessary in the daytime. Nitrite of amyl and 
chloroform should not be used continuously, but should be 
resorted to from time to time to stop violent spasms. If 
bromism should be produced, chloral and opium should be 
relied on; or, cannabis indica may be substituted for the 
bromides. Where there is much cerebral congestion a blister 
may be put on the nape of the neck {^Philadelphia Medical 
Times, Oct. 13, 1877, and London Medical Record, Dec. 15, 

1877, P- 5°°)- 

Nerve-stretching has been recently advocated as a remedy 
in tetanus. It is an operation first introduced and recom- 
mended by Nussbaum for the cure of neuralgia and other 
painful and spasmodic nervous affections. Within the last 
few years it has been tried in this country in the treatment 
of tetanus, by Milner, Verneuil, Callender, Eben Watson, and 
by Mr. Henry Morris in the Middlesex Hospital, London, 
and by Surgeon-Major J. J. L. Ratton, in Madras Medical 
College, with varying success. M. Verneuil's case occurred 
after a crush of the hand. Traction was made on the median 
nerve at the elbow, and on the ulnar near the wrist. The 
man completely recovered, but no particulars are given as to 
the duration of the case, or as to its being acute or chronic. 
Two cases reported by Dr. Eben Watson both died. The 
patient operated upon and reported by Mr. Henry Morris al- 
so died. The case differed from the others in its very great 
severity and acuteness; and he did not think that the pro- 
gress of the case had been in the least retarded or mitigated 
by the nerve-stretching. On the contrary, the course of the 
symptoms seemed to become more severe and more rapid; 
and he could not help expressing his conviction that nerve- 
stretching in tetanus would not prove a favorable mode of 
treatment. It seemed to be unscientific in principle; and so 
far as experience went, most unsatisfactory in practice. The 
idea was to destroy the conductivity of the nerve-trunk, so 
as to cut the spinal cord off from its communication with the 
peripheral nerves at the seat of injury. In doing this a very 
severe shock or irritation was likely to be excited by the 
nerve-stretching itself; so that the condition of the cord, be 
it what it may, whether a material change, a state of excite- 
ment from irritation, or a " bad habit " induced by a " de- 



4l8 TETANUS. 

praved current," seemed more likely to be aggravated than 
mitigated by a new and great disturbance of the same nerve 
channel at a spot much nearer to the spinal centre. But the 
operation is still sub judice {Brit. Med. Journ., June 21, 
1879). 

On the other hand Surgeon-Major Ratton writes hopefully 
of the operation, aided by the administration of chloral. 
The case he relates is that of a strong Hindoo woman thirty 
years of age, in whom symptoms of lockjaw appeared after 
having taken a cold bath on the third and last day of a 
menstrual period; and in whom there were also deep syphilitic 
ulcers over the left ankle, some with sinuses and tense 
cicatricial bands. He regarded the case as one of traumatic 
tetanus, the symptoms of which rapidly developed into an 
explosion of acute tetanic violence, which he believes would 
have killed the patient but for the nerve-stretching; and 
which, at the same time, would not have saved the patient 
but for the chloral. The sciatic nerve was stretched with 
" the force required to lift a three-pound weight " for the 
space of two minutes, and afterwards jerked once or twice 
with about double that force before being replaced. Not a 
single spasm recurred for 18 hours after the operation, when 
slight spasms reappeared; and if at this time chloral had not 
been pressed, the spasms would have gathered strength. 
This is the fifth time Surgeon-Major Ratton has stretched 
the sciatic nerve for traumatic tetanus, and each time the 
operation has suppressed spasm for many hours; and if dur- 
ing these valuable hours of rest, chloral is properly plied, he 
believes the chances are that spasm will not return. He has 
given chloral very freely, so as to maintain narcotism for 
ten days. During the three critical days of the case of the 
Hindoo woman, on and after the operation day, she had 300 
grains of chloral daily. In such cases there is a great toler- 
ance of chloral. In this particular case he purposely re- 
frained from operating until the symptoms of tetanus were 
alarming, for he desired to test the value of nerve-stretching 
in acute cases only, for subacute cases often get well of 
themselves, while acute cases never do. He doubts if any 
treatment will avail to cure acute tetanus unless age (say 
about thirty years, or prime of life) and stamina of constitu- 
tion are with the physician. In this case the duration of the 
disease was twenty-three days. It is only the strong who 
can hope to battle through the exhausting effects of tonic 
and clonic tetanic spasms prolonged for days, generally with 



TINEA DECALVANS TINEA FAVOSA. 4I9 

insufficient nourishment, often for days at a time able to take 
nourishment by rectal alimentation only; yet considering the 
well-merited reputation of tetanus as a fatal disease, surely 
it is a solid gain that even a few cases may, under certain 
circumstances, be saved by the resources of modern medi- 
cine (Brain, Part VII., Oct., 1879, p. 483). 

Tinea Decalvans. — Definition. — A fungous disease caus- 
ing the formation of rounded or oval patches of baldness, 
sometimes solitary, more generally multiple. It affects the 
hairy scalp principally; but the beard, the genital organs, 
and hairy portions of the skin may also suffer. 

Treatment consists— (1.) In preventing the spread of the 
disease circumferentially. All the hairs within a quarter of 
an inch of the circumference of the patch ought to be care- 
fully extracted. The head should be washed daily with soft 
or black soap. All the downy hairs within the patch must 
be similarly removed till healthy hairs begin to grow; and 
some of the parasiticide lotions or ointments must be in- 
dustriously used. (2.) Stimulant?, or even blisters, must be 
applied to the surface of the bald patch after the fungus has 
been destroyed. A mixture of equal parts of collodium 
and of ether cantharidalis (collodium vesicans) is the most 
useful stimulant. The following lotions may be found ad- 
vantageous alternately with the collodium stimulant 
namely: — 

r>. Liquor Ammoniae, 3 iss; 01. Olivas, 3 ii- ; 01. Macidis, 
3 ss. ;Spiritus Rosmarini, 3 iv. ; Aq. Rosse, 3 ii. ; misce bene. 
To be used night and morning, applied over the bald 
patches. 

Mr. Startin recommends a lotion nearly similar, namely: — 

3. Spt. Ammon. co., f 3 i- ; Glycerine, f§ss.; Tinct. 
Cantharidis, f 3 i- to f 3 ii.; Aq. Rosmar., J viii. 

Mr. Erasmus Wilson recommends the following: — 

Tfc. 01. Amygdal.; Liq. Ammoniae, aa 3 i.; Spt. Rosmarini; 
Aq. Mellis, aa § ii.; misce. To use as a lotion. 

Of course, none of these agents have any good result if 
there are no bulbs or roots of hair left whose growth can be 
stimulated by such application; but when hair falls off, or 
breaks away after debilitating illness, or from dryness of the 
scalp, they are often useful. 

Tinea Favosa. — Definition. — A fungous parasitic disease, 
composed of cup-shaped scabs, sometimes distinct and 
separate, at other times indistinct or confluent. The fungi 
(Achorion Schonleinii Puccinia favi) are capable of being 



420 TINEA FAVOSA. 

implanted by transference from one person to another. The 
hairy scalp is its most common site, but the disease may be 
developed on the face, neck, or limbs. 

Treatment. — The treatment of the various forms of favus 
is now very strictly determined. Some practitioners, how- 
ever, still rely entirely on a constitutional treatment, such as 
small doses of rhubarb and soda, small doses of mercury, 
some preparation of iron; or on vegetable tonics, as the in- 
fusion of cascarilla or compound infusion of gentian. With 
such treatment, if the health improves, it is believed the 
fungus will spontaneously disappear. Others, again, as 
entirely rely on a local treatment, attempting to exterminate 
the disease by cauterization, or by applying some favorite 
ointment. As in the last described disease, the crypto- 
gamous parasite must be destroyed, and its germs eradicated. 
The best method to accomplish this is, in the first instance, 
to shave the head and apply a poultice till all the scabs, or 
very nearly so, are removed; and this being affected, the 
whole hairy scalp, or site of the favus fungus, should be 
anointed with some of the following applications: — The tar 
ointment (ungt. picis liquidae) has hitherto been the ortho- 
dox application. This ointment should be washed off night 
and morning with soft soap and water, and be as often re- 
applied. The head should be shaved twice or thrice a week, 
and where there are other children, the affected child should 
be isolated as much as possible, to prevent the disease 
from spreading. This form of porrigo, in the early 
stages, will sometimes yield by washing the part with the 
oleum terebinthinae night and morning, and cutting the hair 
close. Two parts of carbolic acid to three parts of glycerine 
and water used twice a day, with the daily use of carbolic 
acid soap, have been also found of service. 

But favus is more often rebellious to every mode of treat- 
ment. It has been known to yield to fomentations, or to 
bread poultices. The application of the lunar caustic round 
the patches, about a line from their outer margin, is another 
favorite method of treatment. In the later periods of the 
disease, Dr. Willis recommends — 

A solution of sulphate of copper, in the proportion of 
seven grains to ten ounces of water; or of the nitrate of 
silver in the same proportions. The mild ointment of the 
nitrate of mercury, a salve of the black sulphuret of the 
same metal (sulphuretum hydrargyi nigr., 3 j. ad. 3 ij., 
adipis 3 j); the unguentum picis, an ungent of the cocculus 



TINEA TONSURANS. 42 r 

Indicus ( 3 j. to 3 ij-, adipis f j.,) may be tried one after 
the other; and in different instances each may have the 
merit of the cure. 

The most effectual remedy is unquestionably the eradica- 
tion of the affected hairs, and the use of such parasiticides 
as have been already mentioned under the different forms 
of Tinea. Dr. Anderson finds that when favus affects the 
head, all treatment is absolutely useless except epilation. 
The other methods are merely palliative, the disease re- 
appearing whenever the treatment is stopped. Treatment 
with olive oil is very useful in many cases before proceeding 
to epilation. After the hair is cut short, and the favus 
crusts removed with poultices, the parts affected should be 
smeared thoroughly night and morning with fresh almond 
oil; and once or twice a week the head should be washed 
thoroughly with soft soap and warm water. After a few 
weeks of this treatment the hair becomes less friable, and 
epilation is much more easily and efficiently performed, and 
does not cause so much local irritation. The hairs are to be 
removed singly with the forceps, not pulled out along with 
all the healthy growth in their neighborhood, as used for- 
merly to be done by the barbarous application of the pitch- 
cap. When favus occurs on surfaces not particularly cov- 
ered with hair it yields at once to the application of a solu- 
tion of sulphate of copper, or of the nitrate of silver in 
water, or to. the solution of sulphuric acid, as recommended 
by Sir William Jenner. The treatment of favus recom- 
mended by Robin and Bazin is epilation, and the applica- 
tian of the corrosive sublimate solution, or of acetate of 
copper ointment (i part to 500 lard), to kill the plant still 
remaining adherent to the hair follicle 

Tinea Tonsurans. — Definition. — An affection implicat- 
ing the hairs of the skin, scalp, or chin, and usually assum- 
ing a circular form. The hair becomes dry and brittle, hav- 
ing a tendency to crack or break across. Itching accompa- 
nies the primary eruption, which is generally at first erythe- 
matous, with slight swelling, and a parasitic fungus ultimately 
appears (Achorion Lebertii — Trichophyton tonsurans), which 
had been developing between the epidermis and the true 
skin. The fungus has a pure white color and powdery as- 
pect. It covers the epidermis between the hairs, and forms 
around them a complete white sheath. Inflammation of the 
hair follicles and of the surrounding tissues occurs; and when 



422 TINEA TONSURANS. 

pus forms, the fungus is destroyed at the expense of obliter- 
ation of the roots of the hair, when perfect baldness ensues 
(Bazin, Anderson). 

The Treatment of ringworm has been long one of the most 
difficult points in dermatology. Its principles, however, are 
now well understood, and few cases resist the proper meas- 
ures. The essential point is to apply to the roots of the hairs 
a preparation which may destroy the fungus; if this can be 
done, the disease is cured. It is first of all necessary to re- 
move the hair. This is in part generally accomplished be- 
fore the case comes under treatment, by the course of the 
disease; if it has not been sufficiently done, " epilation" can 
be accomplished by a chemical agent, or by extraction with 
pincers. The forceps most suitable for this little operation 
are those about three inches long, having a weak spring, so 
that the hand may not be fatigued in using them. They 
should be made so that the two extremities come together 
very exactly, and do not slide the one upon the other. Each 
extremity should be a couple of lines broad, so that a fascic- 
ulus of hair may be caught up at one time when required; 
and should be furnished on the inside with very fine, but at 
the same time blunt, transverse denticulations, so that they 
may not cut across the brittle hairs. M. Bazin recommends 
an ointment composed of lime and carbonate of soda, of each 
one part, and thirty parts of lard, as an agent to remove the 
hair. The oil of cade, however, appears to be the best de- 
pilatory known, and with this mode of treatment epilation 
with the pincers may be combined. If the hairs are pulled 
out in the proper direction, there is very little pain, especially 
after the sensibility of the skin has been blunted by the use 
of the oil of cade. The removal of the hairs permits a "par- 
asiticide" solution to be applied to the hair follicles, within 
which are the prolific spores of the fungus. For this purpose 
M. Bazin recommends either a solution of bichloride of mer- 
cury (i part to 250 of water), or an ointment of the acetate 
of copper (1 part to 500 of lard), about two grains to an 
ounce of water; and a little alcohol or muriate of ammonia 
should be used to facilitate the solution of the mineral. The 
oil of cade should be mixed with glycerine in the proportion 
of half a drachm to a drachm of the oil to an ounce of gly- 
cerine. Kuchenmeister's experience shows that the alco- 
holic solutions act most powerfully. Dr. Parkes used, with 
excellent effect, a solution of thepernitrate of mercury, about 
one part to thirty or forty of water. This is, however, a very 



TINEA TONSURANS. 423 

powerful remedy, and is to be cautiously used, as it easily 
blisters the scalp; also, an ointment composed of sulphate of 
copper (one part), alum (three parts), and lard (twenty to 
thirty parts, according to the age of the patient). Probably 
a better and safer parasiticide than any of these is sulphurous 
acid (Sir William Jenner). Diluted with equal parts of gly- 
cerine, or with two or three parts of water, it is to be applied 
on a piece of lint to the affected part, and covered with oil- 
silk to prevent evaporation (Med. Times, Aug. 20, 1853). 
The following formula for sulphur may also be used: 

3. Sulphur, fiv.; Hydrarg. Amnion. -chloridi, Hydrarg. 
Sulphuret, a a 3 ii. ; 01. Olivge, §i.; Adipis, §iv.; Creasoti, 
mv. It must be well rubbed into the patches of tinea. 

Or, a lotion of one ounce of hyposulphite of soda in twelve 
ounces of water (Dr. Tilbury Fox). The internal use of cod- 
liver oil at the same time that sulphurous applications are used, 
has also been recommended (J. H. Bennett). My friend, 
Staff-Surgeon Dr. Davidson, has found the following method 
of treatment to succeed, namely: to apply tincture of iodine 
to the affected parts twice a day for fourteen days, and after- 
wards ointment of the bichloride of mercury (Corros. subli- 
mat). After the third or fourth application of the iodine, 
the disease ceases to spread, and the hair (which may have 
been thinning rapidly) ceases to fall off. A kind of crust is 
formed by the application of the iodine, which scales off in 
the form of a scurf when the ointment is applied. Soft soap 
(black soap) applied to the patches of disease at bedtime, 
and washed off in the morning, fits the parts for the better 
reception of other local remedies. Washing the head le fore 
medical treatment is begun, sometimes tends to spread the 
disease to parts of the head which had been sound before. 
Goa powder, called also Bahia powder and Araroba powder, 
first introduced to European medical practice by Sir Joseph 
Fayrer, has also become a remedy, made into an ointment 
composed of 20 grains of the powder, 10 drops of acetic 
acid or common vinegar, and an ounce of benzoin ointment. 
It is applied by means of a hair pencil (Dr. Da Silva Lima). 
Its active principle, chrysophanic acid, has the objectionable 
property of staining; but it forms an efficient ointment in the 
treatment of some forms of ringworm, to to 60 grains to an 
ounce of lard being melted together in an oil-bath. 

The iodide of arsenic in doses of one-tenth of a grain, 
gradually increased to one-fourth of a grain for an adult; one- 
fifteenth of a grain for a child six years old; and from one- 



. 



424 TINrA VERSICOLOR TONGUE, ULCER OF. 

eighteenth to one-twentieth for younger children, improves 
the general health (Neligan, on Diseases of the Scalp). 

Tinea Yersicolor — Definition. — A fungous affection of 
the skin, characterized by one or more broad irregularly- 
shaped patches of a yellow or yellowish-brown color, occur- 
ring most frequently on the front of the neck, breast, abdo- 
men, and groins, having a predilection for those parts of the 
body covered by clothing. The patches do not generally 
rise above the surface of the skin; and there is usually some 
degree of itching. 

Treatment. — Local applications constitute the principal 
part of the treatment. A solution of the bichloride of mer- 
cury, in the proportion of two grains to an ounce of water, 
applied over the affected parts once or twice daily, is gener- 
ally effectual in destroying the progress of the fungus. Mer- 
curial or sulphur baths have a similar effect, either singly or 
combined, care being taken to avoid salivation. The use of 
black soap night and morning is recommended by Dr. An- 
derson, or the use of the following mixture: — 

I£. Bichloridi. Hydrarg., 3i.; Alcoholis, 3SS.; Saponis 
Viridis, et Aquas distillatae, a a 3 iiss. ; 01. Lavandulae, 3i. ; 
misce. To be used night and morning in the same way as 
the black soap; but if the gums get tender, its use must be 
suspended. 

Great attention must be paid to cleanliness. The patient 
should change his flannel clothing very often, and should not 
sleep in the same flannels that are worn during the day. 

Tongue, Inflammation of — See Glossitis. 

Tongue, Ulcer of the. — Dcfinitio \ — Inflammation, sim- 
ple or specific, terminating in ulcers. 

The treatment of syphilitic ulcerations of the tongue varies 
according to the severity and form of the affection. In the 
secondary varieties the local application of solutions of 
chloride of zinc, with washes of chlorate or permanganate of 
potash, are frequently sufficient; but sometimes the applica- 
tion of solid nitrate of silver is desirable. In the tertiary 
forms of syphilitic ulceration, solid nitrate of silver must be ap- 
plied daily, and large doses of iodide of potassium frequently 
administered. In mercurial ulcers, constitutional treatment 
of a tonic character, disinfectant gargles, and generous diet 
are indicated. It may here be mentioned that in all cases 
of diseases of the tongue, all irritants, as spices and pepper. 



TONSILS, ENLARGED TYPHLITIS. 



425 



as well as smoking, sucking of lozenges, or any other measure 
calculated to increase the flow of saliva, must be strictly pro- 
hibited. 

Tonsils, Enlarged. — Definition. — Hypertrophy of the 
tonsil, generally with induration. 

Treatment. — Although enlarged tonsils may be the result 
of constitutional derangement, they in themselves also inter- 
fere with the proper development and health of the body. 
Thus, they constantly obstruct the free passage of air into 
the chest, and thus interfere with the due development of 
the chest and the proper oxygenation of the blood; they give 
rise to an unhealthy secretion in the mouth; they sometimes 
interfere with sleep; and, in the case of adults, they subject 
the patient to repeated attacks of quinsy, with its associated 
conditions of difficult deglutition and pain. 

The importance of removing the diseased and redundant 
portions of the affected gland will be at once evident. 
Tonics, sea-bathing, and other constitutional means, do not 
appear to exercise any beneficial effect in either diminishing 
or arresting the growth of tonsils predisposed to hypertrophy; 
nor are the applications of caustics of the slightest value, 
unless they are so strong as to destroy a large portion of the 
gland. It is better, therefore, to excise the enlarged tonsil 
in all cases when the respiration is affected, or where there 
is disease of the follicles predisposing to frequent attacks of 
inflammation and suppuration. The best method of removal 
is with a guillotine or wire ecraseur. Dr. Mackenzie has 
lately invented a double guillotine, by which, in one opera- 
tion, both tonsils are removed. This is a great desideratum 
in the case of children; as, after one tonsil has been re- 
moved, the practitioner has great difficulty in inducing his 
little patient to allow a second similar operation. Haemor- 
rhage seldom happens after removal of the tonsils; should it 
occur, ice will generally check it; and if this does not answer, 
a few half teaspoonfuls of a fluid containing tannic and gallic 
acids in suspension, slowly sipped, will be certain to stop all 
bleeding. 

Tremor, Mercnrialis — See Mercurial Poisoning 

Typhlitis. — Definition. — Inflammation of the csecum, 
which may lead to ulceration of its mucous membrane, and 
not unfrequently of the entire wall of the bowel. 

Treat?ne?it. — A full dose of castor-oil ( 3 ss. to § i.) is in- 



426 TYPHOID /EVER TYPHUS FEVER. 

dicated if vomiting does not exist. Drastic purgation is not 
to be thought of. The use of enemas through long rectum 
tubes are the most efficient means of relief, which may throw 
up four or five pints of liquid in a continuous stream, so as 
to soften, crumble down, and set in motion the faecal collec- 
tions. Salt, castor-oil, or turpentine, or milk oughi to be 
added to the.nuid injected (Niemeyer). Any effusion left 
may be resolved by the use of iodide of potassium. Leeches 
may be required if pain on pressure continues in the iliac 
region. 

Typhoid Fever — See Enteric Fever. 

Typhus Fever. — Definition. — A continued specific fever, 
having a duration of from ten to twenty-one days, usually 
fourteen, characterized by an eruption on the skin, of a gen- 
eral dusky mottled rubeoloid rash, appearing between the 
fourth and seventh days, at first slightly elevated ; disappear- 
ing on pressure, but, after the second day, persistent, and re- 
maining so for eleven or twelve days ; and often becoming 
converted into true petechiae. Languor and weariness are 
prominent from the first, gradually passing into sluggishness 
of intellect, with confusion of thought, followed at the end 
of the first week by delirium, stupidity, oblivion, and com- 
plete prostration. In still more severe cases, somnolence, 
stupor, and sometimes coma, with tremors, subsultus, and 
contracted pupils supervene, when prostration becomes pro- 
found. The disease may terminate favorably from the thir- 
teenth to the seventeenth day. If it proves fatal, it is gen- 
erally between the twelfth and the seventeenth day, leaving 
no specific lesion in any part of the body, beyond hyperaemia 
and blood changes, softening and disintegration of the heart 
and voluntary muscles t hypostatic congestion of the lungs, 
atrophy of the brain, and oedema of the sub-arachnoid and 
pia mater. Typhus fever is eminently contagious, and oc- 
curs in strongly-marked epidemics (Murcnison). 

General I?idicatiom for Treatment. — They may be summed 
up as a combination of measures to reduce excessive heat, to 
insure proper excretion, and to act on the semi-paralyzed 
nerves; and, "every remedial agent which shall be found to 
promote the elimination of urea, without increasing the de- 
structive metamorphosis of tissue, will deserve a trial in ty- 
phus " (Murchison, p. 268). To reduce heat and to regu- 
late elimination are but secondary indications in the 
treatment of typhus fever, compared with the influence which 



TYPHUS FEVER. 427 

must be exercised over the nervous system ; and one of the 
greatest objects of therapeutics at the present day is to find 
substances which will act on the nerves and the blood, and 
restore them in some way to their normal action. 

Special Imdicatio?is for Treatment. — Our objects in the 
treatment of typhus fever should be, — (1.) To neutralize the 
poison and to correct the morbid state of the blood ; (2.) 
To promote elimination of the poison and the products of 
the destructive metamorphosis of tissue ; (3.) To reduce 
the temperature ; (4.) To sustain the vital powers, and to 
obviate the tendency to death ; (5.) To relieve the distress- 
ing symptoms ; and, (6.) To avert and subdue local com- 
plications (Murchison, p. 265). 

1. In the belief that the morbid condition of the blood in 
typhus fever may be due to the presence of ammonia in some 
as yet unknown combination, the use of mineral acids has 
been recommended by many physicians. Murchison con- 
siders their beneficial effects in typhus as undoubted, and in 
this opinion he is confirmed by the experience of Huss of 
Stockholm, Haller of Vienna, of Mackenzie, Chambers, and 
Richardson, in this country. Huss recommended dilute 
phosphoric acid in doses of twenty-five to forty drops every 
second hour, believing that the phosphorus exerts a special 
influence on the central organs of the nervous system. But 
in the advanced stage, and especially if sweating, numerous 
petechias, or ecchymoses be present, he has recourse to di- 
lute sulphuric acid in doses of fifteen to twenty drops every 
hour or every second hour. Dilute hydrochloric acid is pre- 
ferred by Drs. Murchison, Richardson, Mackenzie, and 
Chambers. It may be given to the extent of half a drachm 
of the dilute acid, mixed with a like quantity of the tincture 
of syrup of orange every three hours. Dr. A. P. Stewart 
has used with advantage the tinctura percMoridi ferri, in 
doses of thirty minims every three hours. Dr. Murchison 
recommends nitro-muriatic acid. He prescribes twenty min- 
ims of hydrochloric acid with ten minims of nitric acid every 
three hours each dose being diluted with the patient's drink, 
such as barley water sweetened with syrup of ginger and fla- 
vored with lemon peel. But if the "typhoid state" is 
developed in a marked manner, dilute sulphuric acid, 
in doses of fifteen to twenty minims every three hours, 
in combination with ether, and small doses of quinine, 
are to be had recourse to, as in either of the following 
formulae: — 



428 TYPHUS FEYER 

1>. Acid. Hydrochlor. dil., mxx. ; Acid. Nit. dil. mx. ; 
Spt. ^ther. Nit., mix. ; Liquor. Cinchonse, raxxx. ; Decoc. 
Scopar. comp., 3 i. ; misce. A draught so composed may 
be administered every third hour. 

Or, IjL Quiniae Sulph., gr. i ; Acid. Sulph. dil., mxx. ad 
mxxx. ; ^Ether. Sulph. mxv. ad mxxx. ; Syrup Aurant., 
mix. ; Decoc. Scopar. comp., 3 i. ; misce. A draught so 
composed may be administered every third or fourth hour. 

When the acids are cautiously administered in smaller 
doses, in conjunction with a few minims of solution of muri- 
ate of morphia (if the bowels be irritable), sweetened v/ith 
syrup of orange peel and diluted with water, the draught is 
generally relished, and the tongue from being dry, and hard, 
and brown, becomes moist and clean (Perry). 

2. Perhaps the best general method to insure proper ex- 
cretion is to supply the system with abundance of diluents 
containing alkaline salts, which are not given in the food, 
and to maintain the action of the kidneys, the bowels, and 
the skin. Plenty of pure drinking water tends to increase 
the flow of urine, and so helps to wash away the products 
of metamorphosis. Chloride of sodium, the alkaline salts of 
potash, and probably also those of soda, tend to aid the for- 
mation of urea, and its elimination. Dr. Murchison has 
been in the habit of ordering large quantities of salt to be 
mixed with the patient's beef-tea. In most cases it was great- 
ly relished, and apparently beneficial. 

Purgatives tend to insure a proper excretion, probably by 
removing from the blood some of the abnormal products 
formed in fever. The great relief which sometimes follows 
their use, as well as the fall of temperature, seems to show 
this. Where there is retention of urea, they aid its elimina- 
tion, because we know that urea passes off sometimes by the 
mucous membrane of the stomach and bowels. The patient 
should be allowed to drink freely of water ; and five grains 
of the nitrate of potash, or a small dose of the tincture of 
digitalis (miv. to mx.), may be given with each dose of the 
nitro-muriatic acid already mentioned. Dr. Murchison re- 
commends nitre whey, prepared by boiling 3 ii. of nitre in 
a pint of milk, and straining ; or a drink prepared by dis- 
solving 3 i. to 3 ii. of the bitartrate of potash in a pint of 
boiling water, flavored with lemon peel and sugar ; but it the 
patient be very prostrate, or if the bowels be relaxed, 15 
minims of the spirit of nitrous ether is to be substituted for 
the nitrate of potash 



TYPHUS FEVER. 429 

Tea and coffee have been recommended in the stupor of 
typhus ; and it is probable that their good effects are due to 
their power of eliminating the urea already formed in the 
blood (Dr. Parkes). The coffee may be given as an extract, 
or as a strong infusion of the powdered berry made in the 
ordinary way. Tea has been recommended as an infusion 
of the green tea leaf. As beverages or common drinks in 
fever, both tea and coffee have been found to relieve the 
headache, the pulse becoming fuller and stronger under 
their use. Bocker, L. Lehmann, and Hammond, all agree 
in showing that in health they greatly lesson the urea 
(Parkes On the Urine, p. 76). To restrain excessive metamor- 
phosis it has been proposed to administer coca — the dried 
leaves of the erythroxylon coca — which, when indulged in 
by a healthy person, prevents for a time the feeling of fa- 
tigue, and diminishes the amount of urea (to be ?) excreted. 
Hence its possible value as a therapeutic agent (M'Bean, 
Brit. Med. Journ., March 10, 1877, p. 291). A drachm to a 
drachm and a half of the tincture is to be given in water 
every four hours ; or an infusion of the leaves may be taken 
when thirsty. 

The action of the bowels is to be maintained by emetics 
and laxatives. In the first instance, if the patient is seen 
early — /. c, before the sixth day — an emetic of ipecacuanha 
(one scruple), and of antimony (one grain), or of carbonate 
of ammonia (two scruples), in place of the antimony, is to be 
administered. If the bowels remain confined after the emetic 
a mild laxative of rhubarb and calomel, or of castor-oil, is to 
be given ; and failing these, or in place of them, a simple 
enema is to be administered (Murchison, p., 277, 2nd Ed.). 
The advantages of emetics are, that they relieve the patient 
to some extent by mitigating or removing headache and gen- 
eral pains. They also reduce the temperature, abate thirst, 
and quiet gastric disturbance. Emetics, however, are con- 
tra-indicated if the patients are unusually weak, or if the dis- 
ease has advanced beyond the first week. Laxatives and 
enemata, however, ought to be repeated daily, if required, so 
as to secure a motion of the bowels once a day. In this re- 
spect the treatment is different from the treatment which 
ought to obtain in enteric fever. Excrementitious matters 
in the intestines must be removed by gentle aperients. The 
dark offensive matters accumulated in the intestinal canal in 
typhus fever may have a secondary deleterious effect on the 
system if they are allowed to remain. Purging, however, is 



43° TYPHUS FEVER. 

to be avoided, and fresh-made compound rhubarb pill mass, 
which tends to stimulate the peristaltic action of the intes- 
tines, is as good a medicine as can be given, followed, if nec- 
essary, or alternated, by a small dose of castor-oil, or by a 
simple enema. 

Diaphoresis is not to be encouraged beyond the insensible 
transpiration of the skin, to remove which the wholesome 
detergent of tepid water sponging is most beneficial. It 
ought to be used twice or three times daily, and quantities 
of Condy's fluid or of muriatic acid ( 3 i. ad Oj.) may be 
mixed with the tepid water (Murchison). The measure 
is a good one in a hygienic point of view ; and it con- 
tributes — 

3. To reduce temperature, the external application of cold 
water, as was once practised to an extreme degree by Currie 
(and originally recommended by Dr. Robert Jackson), has 
been again recently advocated. In health such an applica- 
tion as that of cold water has a great effect in reducing tem- 
perature, and tends to increase metamorphosis of tissue 
(Lehmann, Sanderson). 

4. The vital powers are to be sustained by food in the 
first instance. For this purpose, nourishment ought to be 
given often, and at stated intervals —at least once every three 
or four hours after the fourth day of the fever. Even if the 
patient is asleep, or seems to be so, he must be roused at 
these stated intervals (not oftener) to take his food or his 
stimulants. But if, towards the period of the crisis, the pa- 
tient appears to be in a sound sleep, he ought not to be dis- 
turbed. The indications for treatment just described apply 
to the earlier stages of the fever, up till about the fourteenth 
day. Beef tea, broths, meat juice, bread pudding, arrow 
root, jellies, milk, eggs, and alcoholic fluids, are the foods on 
which the typhus fever patient must be sustained. Alcohol 
in small quantities, as well as tea, coffee, lemonade, soda- 
water, water poured from standing over oatmeal, and taken 
cold or after boiling and then cooling, and other fluids, have 
a directly stimulant action on the nervous system and on the 
organs of circulation ; at the same time, alcoholic drinks di- 
minish the metamorphosis of the tissue elements. Few reme- 
dies, however, require more discrimination in their use ; and 
the following guides for their administration are compiled 
from the careful observations of Dr. Murchison (p. 288, 
2nd Ed.) : — (1.) Patients under twenty years of age do best 
without alcohol ; but most patients over forty are benefited 



TYPHUS FEVER. 431 

by alcohol from the commencement of the second week of 
the illness, or earlier ; while persons of intemperate habits 
require alcohol earlier, and in greater quantity than others. 
(2.) In individual cases the indications for alcoholic stimu- 
lants are mainly derived from the state of the organs of cir- 
culation ; and the profession is indebted to Dr. Stokes (1839) 
for pointing out the importance of cardiac and radial pulses 
as guides for the use of alcohol in fever. The indications 
are, — {a.) Extreme softness and compressibility of the pulse. 
An undulating, irregular, intermitting, or imperceptible pulse 
more imperatively demands stimulants than a merely rapid 
pulse. So also an abnormally slow pulse — e. g., 40 to 60 — 
is a stronger indication for stimulation than a quick pulse. 
(£.) When the cardiac impulse becomes weak, and when the 
first sound is impaired or absent, a liberal allowance of stim- 
ulants is demanded ; and in every case where there are 
doubts as to the propriety of giving stimulants, the heart 
must be examined with the hand and with the stethoscope, 
because the state of the pulse alone is not sufficient to judge 
from. The impulse may be found to diminish progressively 
from the fifth or sixth day to the termination of the disease ; 
and for several days prior to death or recovery it may be en- 
tirely absent. The systolic sound of the heart becomes daily 
more feeble, and ultimately may be quite inaudible, leaving 
the second sound clear and distinct ; and before the first 
sound is altogether lost, it may become so short that it is dif- 
ficult to distinguish it from the second sound. If the action 
of the heart be rapid, its sounds may thus come to resemble 
closely those of the fcetus in utero. A violently excited heart 
all through the disease, with cold surface, cold breath, and 
feeble pulse, demands wine from the first ; but even with its 
judicious use the prognosis in such cases is extremely doubt- 
ful (Stokes, Graves, Murchison). Other indications for 
stimulants may be stated as follows : — {c.) If by raising the 
patient to his semi-erect position a tendency to syncope is 
induced, or great prostration is manifest, with diminished 
strength and volume of the pulse, then stimulation must be 
commenced. (3.) The darker and more copious the erup- 
tion, the more is the necessity for stimulants, especially 
if petechiae are numerous. (4.) Profuse perspiration, 
with no improvement in the general symptoms, requires an 
increased supply of stimulants ; but a burning dry skin is in 
kself an indication against alcohol. Coldness of the ex- 
tremities is an indication for alcohol, especially when at the 



432 TYPHUS FEVER. 

same time the temperature of the trunk is considerably ele- 
vated. (5.) Stupor, low delirium, subsultus, involuntary- 
evacuations, — symptoms generally of the typhoid state, are 
indications for the liberal administration of alcohol ; but the 
propriety of giving stimulants in delirium depends on the 
state of the pulse. If, 011 the trial of stimulants, the patient 
becomes tranquil, they do good, and may be continued ; if 
the reverse, their use must be suspended. (6.) A dry brown 
tongue is an indication for wine or brandy ; and if it becomes 
clean and moist at the edges under the use of either, such 
stimulation is beneficial. (7.) Complications, as a rule, in- 
crease the necessity for stimulation ; and large quantities of 
stimulants are called for if pyaemia, erysipelas, bronchitis, 
pulmonary hypostasis, pneumonia, inflammatory swellings, 
bed sores, or local gangrene shonld supervene. (8.) Alco- 
hol, as a rule, is contra-indicated if there be severe darting 
or throbbing headache, or acute noisy delirium, especially 
when these symptoms co-exist with great heat and dryness 
of the skin, flushing of the face, suffusion of the eyes, and 
little or no impairment of the cardiac and radial pulse. AVhen 
alcohol is given under such circumstances, it should be re- 
stricted to the intervals of the paroxysms of delirium. (9.) 
Scanty urine of low specific gravity, containing little urea or 
much albumen, and suppression of urine, are in themselves 
indications against the use of alcohol. 

The effects of alcoholic stimulation require to be most 
carefully watched throughout the whole period of their ad- 
ministration. Four ounces of wine in the twenty-four hours 
is enough to begin with ; for if the blood be overloaded with 
the products of alcoholic ingestion, further alcoholic stimu- 
lation will lead to increased contamination, and it is rare that 
more than eight ounces of brandy in twenty-four hours are 
necessary. There are differences in the demand for stimuli 
in the typhus of different countries, and in the fever of differ- 
ent epidemics. Dr. Wood tells us that in America cases re- 
quiring wine or brandy are extremely rare. Dr. Stokes says 
that the typhus in Ireland demands large quantities of wine. 
In Scotland, also, wine is the great mainstay in the treatment 
of typhus fever, requiring often to be administered largely. 
Port, sherry, marsala, madeira, brandy, gin or whiskey, pos- 
sess no peculiar advantages apart from the alcohol contained 
in each. Spirits contain 50 to 60 per cent, of alcohol, sherry 
and port from 17 to 24 per cent., and malt liquors from 6 to 
8 per cent. Two fluid ounces of spirit will thus be equal to 



TYPHUS FEVER. 433 

five or six of wine, and spirits ought to be given diluted ; and 
if the prostration is great, and when the skin is cold and 
covered with perspiration, the best stimulant is brandy or 
whiskey punch, given as hot as it can be taken, in small quan- 
tities at a time, frequently repeated. In urgent' cases stimu- 
lants ought to be given every hour ; and, as a rule, a larger 
quantity will be required during the night and early morning 
than in the daytime, for it is usually towards morning that 
temperature tends to get low, and the vital powers are at 
their lowest ebb (Murchison). At the same time it must 
ever be remembered, as Sir William Jenner justly observes, 
that " in no disease is the advantage of refraining from med- 
dling more clearly displayed than in typhus fever ; and in no 
disease is the prompt use of powerful remedies more clearly 
indicated. It is in determining when to act and when 
to do nothing, that the skill of the physician as a curer of 
disease, in the case of fever is shown. Interfere by deple- 
tion or stimulation when nothing should be done, and the 
patient is lost, who, if it had not been for you, would have 
been safe. Refrain from depletion or withhold stimulants 
when the one or the other is required, and the patient sinks 
into that grave from which judicious treatment might have 
saved him." 

A large, well-ventilated apartment, fresh air, a cool, but 
not a cold atmosphere, quiet, abstinence from solids, and a 
free supply of water, milk and water, coffee, weak broth, 
beef tea, according to the discretion of the physician, are 
the conditions and remedies on which a large majority of 
cases will recover. But the patient must be constantly and 
carefully watched. There is no disease where the attentions 
of a well instructed nurse are more demanded ; and there is 
no class of patients in hospitals so apt to be neglected by 
the attendants, especially as to the regular administration of 
the remedies prescribed. It is not uncommon to find that 
the wine allotted for the day has been administered at a 
draught, when it ought to have been given in small quanti- 
ties at regular intervals, with care and watchfulness. How 
often do we see almost hopeless cases recover under the careful 
nursing of an intelligent person, regulated by the dictates of 
common sense and conscientious solicitude, guided by the 
judicious directions of a physician who knows well the na- 
ture of the disease with which he has to deal ! The nurse 
ought to note down the hours at which food or medicine has 
been given, or any remarkable change in the symptoms. She 
28 



434 TYPHUS FEVER. 

might also, if she were instructed, take observations with the 
thermometer, for the information of the physician at each 
visit. Dr. Murchison recommends that, in urgent cases, 
food and alcoholic stimulants must be persisted in as long as 
the patient is able to swallow ; and even when he can no 
longer swallow, the case is not to be given up ; for he has 
seen cases where life appeared to be saved by frequent ene- 
mata of beef-tea and brandy after the patient had ceased to 
take anything by the mouth. 

Of special symptons which call for relief, the most urgent 
is generally headache. If headache should persist after de- 
lirium sets in, with a rapid pulse (e. g., 120), attended with 
nausea, some saline, effervescing mixture, with four drops of 
dilute hydrocyanic acid, may be given every six hours. In 
the persistence of headache, dry cupping, such as has been 
recommended by Dr. Sieveking, might furnish an aid to 
guide the treatment, by determining whether it may not de- 
pend upon repletion or upon emptiness of the cranial ves- 
sels. When applied to the nape of the neck, dry cupping 
may afford relief, if repletion has to do with the continuance 
of headache. Under such circumstances the face is gener- 
ally flushed, the conjunctivae red, and the skin dry and hot. 
If the dry cupping does not relieve such symptoms, the hair 
must be shaved off the head, and the scalp covered with 
crushed ice inclosed in a bullock's bladder, or recourse may 
be had to cold affusion. The application of cold water is 
best effected by bringing the patient's head over a basin at 
the edge of the bed, and having a vessel arranged so that the 
cold water (at 40 or 50 Fahr.) may drip continu- 
ously from a height of two or three feet upon the 
head (Murchison). A skein of worsted arranged in the 
water, with the ends overhanging the basin will main- 
tain a constant flow of water from the basin, which may 
be directed to fall upon the scalp. Dr. Murchison recom- 
mends that in young subjects two or four leeches may be 
applied to the temples; and in aged or infirm persons warm 
fomentations to the head are advisable (Graves and Murchi- 
son); a double fold of lint moistened in warm water and 
vinegar, is to be laid over the scalp, covered with oiled silk, 
and the application renewed every three hours. But if 
anaemia is the cause of the headache, as may be suspected 
from the state of the vascular system, then stimulants are 
called for. Four to six ounces of wine may be given in 
divided doses during the day and night of twenty-four 



TYPHUS FEVER. 435 

hours. If the pulse continues to get weaker, the wine must 
be increased. It must be borne in mind that the headache 
of typhus naturally abates about the eighth day; but it is 
sometimes rendered worse by sleeplessness; and if the reme- 
dies for headache do not relieve it, nor tend to induce sleep, 
then opiates may be given, combined with antimony, if the 
skin be dry and hot and the pulse of good strength. Dr. 
Murchison thinks that the employment of opium in typhus 
is more dreaded than it ought to be. The dose of opium 
should be given about 9 p. m., followed in two hours by half 
the dose if the patient does not sleep. The form of the 
opiate and dose may be ten to twenty minims of Battley's 
solution, or fifteen minims of the solution of the bimeconate 
of morphia, or five grains of the opium pill or compound 
soap pill of the British Pharmacopoeia. Dr. Murchison 
teaches us to distinguish two forms of delirium as a guide to 
the administration of opium, combined with antimony in the 
one form, and with ethereal stimulants in the other. When 
the condition of the patient approaches more to that of 
delirium ferox, the cardiac and radial pulses being of good 
strength, after trying the cold affusion, and remedies already 
mentioned, then opium combined with antimony ought to be 
given without delay, as in the following prescription: 

r>. Liq. Opii. Sedat. (Battley's) m lx; Antim. Tart., gr. if 
ad gr. ii.; Aquae Camph. | vi.; misce A large spoonful o. 
this mixture is to be given every hour until sleep is induced. 

On the other hand, if the delirium approaches in its char- 
acter that of delirium tremens, the radial pulse is usually 
quick and feeble, the cardiac impulse diminished, and the 
first sound of the heart more or less inaudible, then the 
opium must be combined with alcoholic or other stimulants, 
the amount being regulated by the state of the pulse and 
heart. Dr. Murchison suggests the following prescription: 

fy. Liq. Op. Sed. (Battley's) 3 ss.; Spt. ^Etheris, m lx.; 
Aquae Camph., ad |iii.; misce. Commence by giving two 
tablespoonfuls of this mixture, and repeat it every hour till 
sleep is obtained. 

Or opium to the amount of half a grain may be combined 
with three grains of camphor in a pill, and such a pill may be 
repeated, -f necessary, every two hours. 

Cases requiring such treatment ought to be seen at least 
three or four times daily. If dyspnoea is urgent, and lividity 
of the face betoken pulmonary lesion, defective arterializa- 
tion of the blood and venous congestion of the brain, opium 



436 TYPHUS FEVER. 

in any form must be withheld; and it must likewise be dis- 
continued if any tendency to stupor supervene, or if there be 
any marked contraction of the pupil — e. g., " the pin-hole 
pupil " of Dr. Graves. This physician proposed the use of 
belladonna in such cases, and he, as well as Dr. Benjamin 
Bell and Dr. Murchison, bear their united testimony to its 
usefulness. Dr. Craves prescribed it as follows: 

5. Ext. Belladonnas, gr. i.; Ext. Hyoscyami, gr. vi.; Pil. 
Hydrar., gr. xxx. ; misce. This mass being divided into six 
pills; one may be given every three hours. 

Dr. J. Harley recommends 15 to 20 minims of the tinc- 
ture every four hours; or to inject hypodermically from -fa 
to 4*5- of a grain of sulphate of atropia. But digitalis is the 
remedy on which Dr. Murchison places most reliance. 
From 15 to 20 minims of the tincture; or from 6 drachms 
to 3 ounces of the infusion may be given in the twenty-four 
hours (1. c, p. 284). Musk and camphor are stimulants of 
very great value, which have fallen into unmerited neglect. 
Camphor may be given in emulsion in doses of five grains 
every two hours; or in the form of an enema in doses of a 
scruple. Huss and Graves also bear testimony to the good 
effects of these remedies. In a case of complete sleepless- 
ness Dr. Graves gave the following combination of these 
medicines with the best results: 

IJ. Antim. Tart., gr. ss.; Pulv. Moschi, gr. x.; Camphor, 
gr. v.; Tinct. Opii., mx; Aquae dil., 3L; misce. A similar 
draught may be given every two hours; and after the third 
dose the patient will generally fall into a quiet sleep. 

The hydrate of chloral has been found to be preferable, in 
certain circumstances, to opium in typhus fever. As a seda- 
tive and hypnotic, it is successful in every form of cerebral 
excitement; but it seems to have a more immediate and per- 
manent curative action on cases of acute delirium at the 
acme of typhus, than in the delirium tremens of the second 
and third weeks, when the blood is loaded with the products 
of the fever. It is also of use where there is bronchitis and 
congestion of the lungs, when opium may not be given. 
With regard to the dose, 40 grains is found to be a poisonous 
dose in typhus, producing depression and irregularity of the 
heart's action. All the benefits without the dangers may be 
obtained with 20 grain doses for adults; 2 grains for chil- 
dren of one to two years; 3 grains for three years; and 10 
grains for children from nine to fourteen years. It is to be 



URINE, SUPPRESSION OF. 437 

given in an ounce of water, sweetened with half an ounce of 
syrup (Dr. J,. B. Russell). 

When there is danger of stupor passing into profound 
coma, the best effects may result from a small cupful of a 
strong infusion of coffee, given every three or four hours, 
employing at the same time such measures as have a deriva- 
tive action on the kidneys — e. g. f dry cupping; mustard 
poultices to the loins; wet compresses of thickly folded flan- 
nel, wrung out of hot water, passed round the loins, and cov- 
ered with a piece of water-proof cloth, retained in its place 
by a bandage or towel. These remedial agents are all the 
more necessary if the urine contain either blood or albu- 
men. At the same time free evacuation from the bowels 
should be secured by a purgative, or by a turpentine enema. 
If the lethargic state supervenes early, and before there is 
great exhaustion, the douche has been found to be of great 
service as a stimulant, provided there be considerable eleva- 
tion of temperature, and little irritability of the nervous sys- 
tem (Todd, Armitage, Murchison). 

The region of the bladder should be examined by the 
physician at least two or three times daily, by manipulation 
and percussion, and if there be the slightest doubt as to its 
containing urine, the catheter must be introduced. 

Urine, Suppression of. — Definition. — A complete or 
partial suspension of the functions of the kidney, by which 
the quantity of urine is greatly in defect, or its secretion en- 
tirely suppressed. 

Treatment. — When suppression does not depend on any 
morbid condition of the blood, and is primary, the patient 
should be placed in a warm bath, and be purged by substan- 
ces that act on the kidney, as the neutral salts. Indeed, if 
the case be slight, purging by any cathartic is sufficient. If 
this method should not succeed, m x. to xxx. of the tinct. 
cantharides should be tried every four or six hours, accord- 
ing to the urgency of the case. Many physicians prefer a 
tonic treatment, as the camphor mixture and ether, or the 
tinct. ferri muriatis m xxv. to 1. Belladonna is a useful remedy 
and so also is digitalis applied as a fomentation of the fresh 
leaves over the abdomen ; or an ounce of the tincture may 
be added to a warm linseed poultice, or the dried leaves may 
be made into a poultice, to which half an ounce of the tinc- 
ture may be added. It is chiefly in cases in which the pulse 
is rapid that digitalis is suitable ; and the urine will not begin 
to flow till the digitalis has reduced the action of the heart 



43^ URTICARIA UVULA, ELONGATED. 

(J. D. Brown, in Medical Times, January 25, 1868). In the 
suppression of urine attending cholera, Dr. E. Goodeve rec- 
ommends the following : — 

I£ . Tinct. Digitalis, m v. to m x. ; Spr. ^Ether. nit., m 
xxx. ; Liq. Ammon. Acet, m lx. ; Aq., f § i. ; misce. Such 
a draught may be taken every three or four hours. (Rey- 
nold's System of Medicine, Vol. I., p. 183.) 

The treatment of symptomatic anuria resolves itself entirely 
into that treatment which will remove the primary disease. 

Urticaria. — Definition. — An eruption of little solid elastic 
eminences, roundish or oblong, pale in the centre, and red at 
the circumference. These are commonly called " wheals," 
similar to the results from the strokes of a lash. 

Treatme?it. — Emetics and purgatives in the first instance ; 
afterwards the correction of faulty digestion. The surface 
of the eruption may be dusted over with flour ; or the fol- 
lowing lotion may be used : — 

Jfr . Carbonatis Ammonias, 3 i. ; Plumb. Acetatis, 3 ii. ; 
Aquae Rosarum, 3 viii. ; 

In the chronic form, especially associated with uterine irri- 
tation or ovarian tumors, I have found bromide of potassium 
of much benefit. It ought to be given in a full dose of ten 
grains twice daily, which is to be doubled at bedtime. Qui- 
nine is also useful, combined with rhubarb and carbonate of 
ammonia. 

rjt. Sulphatis quiniae, gr. xii. ; Solve in Glycerinse, m ii. ; 
Pulv. Rhei., gr. xxiv.; Carb. Ammon., gr. xviii. ; misce et 
divide in pil. xii. — Signa, " One three times a day." 

Uvula, Elongated. — Definition. — Relaxation or paralysis 
of the uvula, which becomes so elongated that its top may 
touch or rest upon the surface of the tongue. 

The Treatment of elongated uvula must depend on the de- 
gree of relaxation present, and the previous duration of the 
affection. Slight and recent cases often get well by the per- 
severing use of astringents. Gargles, containing tannin, 
rhatany, or perchloride of iron, lozenges, and local applica- 
tions, may all be used with advantage ; and, indeed, it is 
found convenient to brace up the mucous membrane by em- 
ploying these different methods at the same time. When 
the uvula has been considerably relaxed for some months the 
elongated portion should be snipped off. While hardly any 
slight affection of the throat produces such serious symptoms 
as elongation of the uvula, there is no slight operation that 






VARICELLA — VERTIGO, AUDITORY. 439 

gives such complete and permanent relief as its removal. 
Should any haemorrhage follow the operation, treatment simi- 
lar to that recommended after excision of the tonsil must be 
adopted. 

Taricella — See Chicken Pox. 

Yariola— See Small-Pox. 

YertigOj Auditory.— Definition.— K condition charac- 
terised by sudden attacks of vertigo, paroxysmal in their oc- 
currence, depending on a morbid state of the organ of hear- 
ing, and especially with lesions of the semicircular canals. 

Treatme?it. — Of practical importance in the treatment of 
labyrinthine vertigo, and at the same time in illustration of 
its pathology, it is to be remembered that the tympanum is 
supplied with arterial blood from the carotid, and its veins 
discharge into the jugular; that the labyrinth is supplied by 
the vertebral, and its veins discharge into the superior pe- 
trorsal sinus; that the vertebral artery derives many of its 
vaso-motor nerves from the inferior cervical ganglion; and 
that these nerves communicate with the brachial plexus. 
The same ganglion furnishes the inferior cardiac nerve — the 
principal inhibitory nerve of the heart. Besides these con- 
nections a fasciculus is given off from the pneumogastric, 
near the recurrent laryngeal, to the lower cervical ganglion. 
We have, therefore, in this ganglion an organ connecting the 
upper extremities, heart and upper portion of the digestive 
tract, with the labyrinthine circulation. From any irritation 
there may consequently arise a diminished inhibition, which 
will relax the walls of the vertebral artery, and so cause 
pressure on the endolymph with consequent vertigo (Woakes, 
Chicago Med. Jour, and Exam. , Nov. 1878). 

Hence such vertigo does not necessarily imply previous 
disease of the ear. Gunshot wounds of the upper extremi- 
ties are often followed by dizziness (Weir Mitchell). Qui- 
nine, in large doses, and tobacco diminish vascular tonus; 
while bromine, the bromides, and especially hydrobromic 
acid, stimulate vascular innervation. Hence the antagon- 
istic effect of the latter on the tinnitus aurium caused by the 
former (quoted by Mr. D'Arcy Power, Lo7ido?i Medical Re- 
cord, April 15, 1879, p. 152). 

The treatment of labyrinthine vertigo, the result of de- 
structive lesions, can be but palliative; but auditory-nerve 
vertigo, due to irritative lesion, may be more or less relieved. 
Absolute rest is the first essential. The direct treatment of 



44° WHOOPING-COUGH. 

labyrinthine affections is a subject for the special aural sur- 
geon; and it is obvious that when symptoms point to the 
existence of any disease or irritation in the accesjible parts 
of the ear, special treatment should be directed to those 
morbid states. When there is evidence of an irritative pro- 
cess, blistering behind the ear sometimes affords very mark- 
ed relief to the vertigo. Occasionally there may be evidence 
of a constitutional condition on which the aural disturbance 
is dependent. In some cases there may be reason to believe 
that a gouty change in the membranous labyrinth is the 
cause of the morbid action (Hinton, Gowers). Marked re- 
lief is afforded under these circumstances by colchicum and 
potash. In rare cases the vertigo may depend on a syphi- 
litic inflammation of the labyrinth. Such a case has been 
described by Moos of Heidelberg. One of the most severe 
forms of paroxysmal vertigo which Dr. Gowers has seen was 
in a child, with almost complete deafness and every sign of 
inherited syphilis. In all syphilitic cases the specific treat- 
ment for syphilis is, of course, required. 

It has been remarked that certain drugs have a marked 
influence on the organ or nerve of hearing. The effect of 
quinine induced Charcot to employ it, in full doses, in a 
case of auditory-nerve vertigo, with some beneficial result. 
Dr. Gowers has tried it; but he has not found that any 
marked effect was produced on the vertigo. The influence 
of salicylate of soda upon the equilibrium suggested its use 
in this disease. It does not remove the giddiness; but in 
some cases it lessens its intensity, in doses of from five to 
ten grains three times a day. The most unremitting care 
in diet and regimen is necessary. Antacids have been found 
useful in subduing stomachal disturbance, and so arresting 
an actual attack, and carbonate of bismuth has been of use. 
The bromides of potassium and of ammonium have been the 
most beneficial of all medicines in subduing the paroxysms; 
and the good effects of bromide of potassium are increased 
by belladonna, and also by its combination with bark. Other 
sedatives alone, such as opium, Indian hemp, gelseminum, 
and hyoscyamus, are, in the experience of Dr. Gowers, with- 
out effect. The affection is a very obstinate one; but when 
the several factors in the individual cases are sought out and 
corrected, a considerable amount of relief may be afforded 
(Dr. W. R. Gowers). 

Whooping-Coilgh— Sec Hoopi?ig Cough. 



WRITER S CRAMP YELLOW FEVER. 44I 

Writer's Cramp — {See Scriveners Palsey.) 

Yellow Fever— Definition. — A specific fever of a malignant 
and continuous type; occurring, as a rule, only once during 
life, and propagated by contagion. It is attended by yellow- 
ness of the* conjunctivae and skin, delirium, suppression of 
urine, interstitial haemorrhages and haemorrhages from the 
stomach, mouth, nares, and rectum (black vomit, black 
stools), a slow and, at times, an intermittent pulse. It is 
limited to very definite geographical limits, never having been 
known to propagate beyond 48 ° north latitude, nor without a 
temperature of 72 ° Fahr. at least. It has been imported 
into Lisbon, into S. Nazaire (in the department of the Lower 
Loire), into Plymouth and Southampton, where the import- 
ed cases have run their course and proved fatal, but the dis- 
ease did not extend to others. It has also been imported 
and become epidemic as far south as Monte Video. It has 
occurred as high as 4,000 feet above t]ie sea-level (Newcastle, 
in Jamaica). But, as a rule, it is endemic in low districts on 
the sea coast, and rarely occurs over an elevation of 2,500 
feet above the level of the sea. 

Treatment. — An early attention to first symptoms among 
the susceptible is of the greatest value in saving hnman life. 
The diagnosis of cases in which the attack has been said to 
have been ''aborted" by remedies may be questioned, and 
such a belief is opposed to the doctrines of sound pathology. 
Moreover, the " heroic " doses of calomel which were given 
in such cases, combined with quinine, cannot be too strongly 
discountenanced, for " they were first recommended on the 
strength of a crazy hypothesis " alone. The practice is said 
to have frequently proved successful in Jamaica; but ac- 
cording to Dr. Davy, it was not attended with beneficial re- 
sults at Barbadoes, and the American physicians at New 
Orleans have not found it to answer their expectations in 
stopping the fever. The large and frequently repeated doses 
of quinine were often also highly injurious (Lawson). This 
discrepancy may, in some measure, be explained 
by what has been stated at the outset in explaining the path- 
ology of this peculiar fever. It is in cases where the fever is 
of the periodic, paroxysmal, or paludal form, and not 
the continuous or true yellow fever, that quinine 
may be of use, if the system can be brought under its influence. 
The ill effects of quinine in specific yellow fever consist in 
its checking secretion and deranging the circulation within 



44 2 YELLOW FEVER. 

the head. It is an object to keep the bowels freely open, 
and to get the skin to act freely. The main object of the 
physician should be to moderate excessive action in any 
organ, and to endeavor to bring about as complete a crisis 
as possible about the fifth day, which seems to be the natural 
period of resolution of the disease. For this purpose noth- 
ing is of more importance than to re-establish the secreting 
function of the colon, and to obtain fceculent evacuations — ■ 
not mere bilious discharges, but proper dark-brown fceculent 
stools (Lawson). Gentle excitement of an extensive portion 
of the lining membrane of the colon, with frequent copious 
enemata of a pint and a half of warm water, in which a table- 
spoonful of common salt has been dissolved, and to which 
has been added a tablespoonful of olive-oil, or more stimulat- 
ing enemata, such as of turpentine, deserve a full and careful 
trial. All the depurative functions must be kept in activity. 
Turpentine is recommended by Dr. Copland, by Dr. Archi- 
bald Smith, and Mr. Laird of H.M.S. " Medea " — one drachm 
doses by the mouth, or half-ounce doses as a lavement, 
several times daily, using it also as an epithem on the abdo- 
men. "When the mucous surfaces," writes Dr. Blair, "as 
indicated by the tongue, were denuded of epithelium, the 
use of gum water was decidedly beneficial. It lubricated, 
defended, and soothed the raw surfaces. The strength was 
generally three drachms of the purest powdered gum arabic, 
dissolved in six ounces of cold water, and a tablespoonful of 
this given every one or two hours. The patient at last gets 
tired of it; but for thirty-six or forty-eight hours of the most 
critical period of the disease it is used without dissatisfaction, 
and then can be substituted by, or alternated with, smoothly 
and thin made arrow-root. When the heat of surface was 
ardent a wet sheet or blanket was used for the reduction of 
temperature by evaporation, with frequently very good effect 
(and if ice could be obtained, its internal use is well worthy 
of a trial). But in the later stages of the disease, when the 
skin was cool or cold, the patient seemed to have an instinc- 
tive craving for its reapplication, and frequently asked to be 
put into it. There would appear to be two causes for this 
feeling. We find it to exist in cases in which black vomit 
has been copious, and the associating thirst distressing; also 
in cases where there has been no black vomit of any conse- 
quence, and the breath is highly ammoniacal. In the former 
class of cases the stomach ceases to be an absorbing viscus 
in anything like the proportion of its secretions and transu- 



YELLOW FEVER. 443 

dations. The skin is therefore employed in reducing the 
crisis of the blood by the absorption of water, as shipwrecked 
mariners are said to quench their thirst. But not only does 
the skin afford an inlet for the imbibition of diluting fluids, 
but the softening of the cuticle would seem to afford an ad- 
ditional outlet for the noxious elements of the circulation; 
and it is probably in this direction we must in future look 
for auxiliary means of relieving the blood of its poisonous, 
metamorphosed, and effete constituents, the onus of which is 
now thrown on such vital organs as the stomach and lungs. 
At one time the heat of the surface was so ardent and persist- 
ent that the wet sheet failed to reduce it effectually. The 
most distressing symptom in yellow fever, both to the patient 
and the medical attendant, is irritability of the stomach; it 
is so constantly present, and so often uncontrollable, that 
the knowledge of every available means of checking it is of 
the utmost importance. The food during the course of 
yellow fever should be of the blandest description — chicken 
tea, arrow-root, sago, and barley-water constituting the chief 
articles; and these should be taken in minute quantities at a 
time when the stomach is at all irritable. This rule applies 
to drinks of all kinds. The patient is greedy for a large 
draught of fluids; but by sucking them through a glass tube, 
or a straw, or a hollow reed of small bore, or by the tea or 
tablespoonful, they are much more likely to be retained. A 
cold infusion of oatmeal was found an agreeable drink for 
Scotch seamen, of which they did not seem to tire. A dis- 
like of sweets was observed among the patients; and when 
lemonade was asked for, the usual quantity of sugar was ob- 
jected to, probably from its rendering the liquid too dense 
for ready absorption by the stomach, and therefore less 
quenching. Tea was found so uniformly to disagree with 
the patients, and cause vomiting, particularly in the ad- 
vanced stages, that at length it had to be expunged from the 
yellow fever dietary. Dilute alcoholic drinks were given 
freely, and with good effect. When brandy could be ob- 
tained pure (tolerably free from acidity and fusel oil), and 
was well diluted with "water, that spirit answered every indi- 
cation. Sometimes the effervescing wines were relished and 
retained, but they are very liable to the objections of con- 
taining foreign matters and the products of mismanaged 
fermentation (Blair). For or five minims of chloroform pre- 
pares the stomach for the reception and retention of food, 
by lessening its irritability; and the dose should be repeated 



444 YELLOW FEVER. 

a short time before food is again taken, as the effect of the 
chloroform is transitory (J. D. Macdonald). On the same 
principle the administration of chlorodyne may be advocated, 
the composition of which is given by Mr. Squire in his " Com- 
panion to the Pharmacopoeia." Lime-water has been also 
found to have a most beneficial effect in allaying vomiting, 
and thus enabling the patient to partake of food; and the 
essence of beef is well adapted for such cases, or beef-tea 
and arrow-root in equal quantities mixed. 

During the course of the disease, auxiliary treatment may 
be required to meet contingent symptoms. This is embraced 
chiefly in the use of sinapisms and stimulating liniments. 
Tenderness over the liver may be benefited by them. Dr. 
Blair writes that when the primary reaction was violent, and 
the face turgid, and the head symptoms severe, arteriotomy 
was performed with benefit. In a few such cases, and when 
the patient was young, strong, and full-blooded, and where 
the dynamic congestions were so violent that the vessels 
yic ded to the turgescence and impulse, and blood-corpuscles 
without tube-casts, or even but a haze of albumen, was pres- 
ent in the urine, a vein in the arm was opened, and free 
bleeding relieved the tension of the vascular system. In 
such cases convalescence was slow and unsatisfactory, but 
the immediate results were beneficial. The severe pain in 
the loins, which is a constant symptom in yellow fever 3 is gen- 
erally associated with renal congestion; and sinapisms or 
stimulating liniments afford great relief to the lumbar pain 
(Macdonald). With regard to the administration of opium 
in any form the rule is, not to give it when there is suppres- 
siDn, or tendency to suppression, of urine. Restlessness and 
sleeplessness are best met by chlorodyne, remembering that 
the effect of yellow fever on the system is to make it sensitive 
to narcotics. The congestion of the kidneys about the fourth 
or fifth day requires watching, so as to diminish the chances 
of suppression, by reducing congestion and preventing the 
closure of uriniferous tubes by accumulated epithelium. 
For this purpose Dr. Lawson recommends cupping, either 
dry or with the abstraction of blood, and the use of frictions, 
with stimulating liniments over the loins. These, with varm 
baths or hot-air baths, deserve a full trial; and small doses 
of acetate of ammonia, with potash or soda, or their salts in 
common use, with diaphoretics (so as to act gently on both 
kidneys and skin), may prove beneficial. 






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